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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


5"Ml-  t: 


8!?.f)f> 


Premature  and  Congenital^ 
Diseased  Infants 


BY 

JULIUS  H.   HESS,  M.D. 

PROFESSOR    AND   HEAD    OF   THE    DIVISION    OF    PEDIATRICS,    UNIVERSITY    OF    ILLINOIS 

COLLEGE    OF  MEDICINE;    CHIEF   OF   PEDIATRIC   STAFF,    COOK   COUNTY   HOSPITAL; 

ATTENDING   PEDIATRICIAN  TO  COOK  COUNTY,  MICHAEL  REESE  AND  ENGLE- 

WOOD  HOSPITALS;  CONSULTING  PEDIATRICIAN,  MUNICIPAL  CONTAGIOUS 

HOSPITAL  AND  WINFIELD  TUBERCULOSIS  SANITARIUM,   CHICAGO; 

MEMBER    OF  ADVISORY    BOARD    CHILDREN'S    BUREAU, 

DEPARTMENT  OF  LABOR,  WASHINGTON,  D.  C. 


ILLUSTRATED   WITH    189    ENGRAVINGS 


LEA   &    FEBIGER 

PHILADELPHIA   AXD    NEW   Y  O  R  K 
192  2 


S<H   £ 


Copyright 

LEA  &  FEBIGER 

1922 


Printed  in  u.  s.  a. 


lAlS 

/f/0 

If  A3. 


In  the  name  of 

CLARA  MERRIFIELD  HESS 

This  book  is  affectionately  dedicated  to  the 
most  helpless  of  the  human  race 

THE  INFANT  BORN  PREMATURELY 

particularly  needful  of  aid  in  its 
struggle  for  existence 


624297 


PREFACE. 


In  the  absence  of  any  definite  collection  of  material  on  the  care 
of  prematurely  born  human  infants,  I  have  attempted  to  compile 
information  taken  from  many  sources.  The  foundation  of  this 
work  with  premature  infants  was  laid  in  the  researches  of  the 
French  obstetricians  and  was  adopted  and  further  popularized  by 
English  and  German  physicians. 

The  growing  importance  of  the  subject  is  indicated  by  the  increase 
in  premature  births  during  recent  years  revealed  by  vital  statistics. 
Of  2806  deaths  of  infants  occurring  in  Chicago  during  one  year, 
739  deaths  in  the  first  month  of  life  were  due  to  prematurity.  Of 
860  who  died  during  the  first  twenty-four  hours,  399  deaths  were 
due  to  premature  birth,  while  of  1700  who  died  during  the  first  week 
of  life,  588  deaths  were  due  to  premature  birth. 

A  study  of  the  etiological  factors  predisposing  to  premature 
birth  emphasizes  the  necessity  for  proper  prenatal  care  of  the 
mother,  thus  eliminating  a  large  group  of  premature  births  pre- 
cipitated by  her  overwork  and  her  anxiety,  or  by  trauma,  as  well  as 
by  improper  hygiene  and  insufficient  and  improperly  balanced  diet. 
The  general  experience  of  workers  who  have  interested  themselves 
in  prenatal  care  of  the  mother  in  its  larger  aspect  proves  that 
careful  following  of  scientific  instructions  inevitably  decreases  the 
number  of  premature  births  coming  under  observation. 

Many  diseases,  such  as  syphilis  and  nephritis,  which  are  direct 
causes  of  premature  birth,  are  amenable  to  treatment  which  will 
prolong  the  intra-uterine  life  to  the  natural  period,  or  at  least  to  the 
point  where  prenatal  development  is  compatible  with  post-natal 
existence.  Proper  preparation  for  the  care  of  these  infants  will 
justify  the  induction  of  labor  prior  to  full-term  when  pathologic 
conditions  exist;  moreover  this  procedure  may  be  undertaken  at  a 
much  earlier  time  than  when  proper  facilities  are  not  available. 

In  the  United  States  the  care  of  premature  infants  has  not  received 
the  general  attention  of  the  medical  profession  which  it  merits. 
Facilities  for  the  care  of  such  infants  are  lacking.  first,  because 
special  obstetrical  hospitals  in  most  instances  decline  outside  cases, 
and,  second,  because  comparatively  few  general  hospitals  are 
properly  organized  to  undertake  the  special  care  required.     Proper 


VI  PREFACE 

handling  of  these  infants  demands  a  thorough  knowledge  of  their 
immediate  needs.  The  first  intimation  of  coming  labor  must  be 
met  by  preparation  for  the  infant's  reception  in  order  to  avoid  the 
dangerous  period  of  exposure  immediately  after  birth  which  is  a 
primary  cause  of  the  high  mortality.  If  a  sudden  lowering  of 
temperature  produces  fatality  in  some  cases  in  full-term  infants, 
how  much  more  likely  it  is  to  produce  fatality  in  an  immature 
infant,  whose  organs  are  not  completely  developed,  who  is  lacking 
in  the  protective  covering  of  body  fat  possessed  by  the  mature 
infant,  whose  vitality  is  low  and  whose  resistance  is  at  a  minimum. 
Coming  from  an  equalized  temperature  of  unvarying  degree  it  is 
precipitated  into  alien  surroundings,  deprived  of  its  usual  nutrition 
and  subjected  to  handling  which,  however  tender,  is  still  a  shock  to 
its  delicate  external  and  internal  structures. 

As  a  part  of  the  great  movement  toward  conserving  and  develop- 
ing the  individual  to  his  highest  point  of  health  efficiency,  as  an 
important  factor  in  national  health,  and  as  an  effort  directed  toward 
the  source  of  a  considerable  morbidity,  the  care  of  premature  infants 
and  the  conservation  of  their  flickering  lives  has  a  prominent  place. 

I  desire  to  acknowledge  my  indebtedness  to  Dr.  Martin  Couney 
for  his  many  helpful  suggestions  in  the  preparation  of  the  material 
for  this  book. 

J.  H.  H. 

Chicago,  1922. 


CONTENTS. 


PART  I. 

ETIOLOGY,  PHYSIOLOGY,  PATHOLOGY. 
CHAPTER  I. 

What  Constitutes  Prematurity  in  the  Infant 17 

CHAPTER  II. 

Classification  of  Prematures 19 

CHAPTER  III. 
Physiology 27 

CHAPTER  IV. 

Pathological  Findings  in  Prematures 103 


PART  II. 

NURSING  AND  FEEDING  CARE. 

CHAPTER  V. 

Maternal  Nursing 107 

CHAPTER  VI. 
Wet  Nursing 114 

CHAPTER  VII. 
Carf.  and  Nursing  of  Premature  Infants 131 

CHAPTER  VIII. 
Methods  of  Feeding 171 

CHAPTER   IX. 
Incubators -05 


vm  CONTENTS 

PART  III. 

GENERAL  DISEASES. 

CHAPTER  X. 

Diseases  of  the  Respiratory  Tract 235 

CHAPTER  XI. 
Diseases  of  the  Gastro-intestinal  Tract 266 

CHAPTER  XII. 
Diseases  of  the  Urinary  Tract 299 

CHAPTER  XIII. 
Diseases  of  the  Nervous  System 301 

CHAPTER  XIV. 
Sepsis 311 

CHAPTER  XV. 

Syphilis 320 

CHAPTER  XVI. 
Tuberculosis  in  Prematures 336 

CHAPTER  XVII. 
Edema  and  Scleredema  ix  Premature  Infants 342 

CHAPTER  XVIII. 
Diseases  Peculiar  to  Premature  Infants 346 


PART  IT. 

THE  OUTLOOK  FOR  THE  PREMATURE. 

CHAPTER  XIX. 
Prognosis 361 

CHAPTER  XX. 

The  Future  of  the  Premature  Infant 377 


LIST  OF  ILLUSTRATIONS. 


PAGE 

Fig.    1. — Case  of  Congenital  Goiter 20 

Fig.    2.— Case  of  Congenital  Thymus 20 

Fig.    3.— Mongolian  Idiot 21 

Fig.    4. — Chondrodystrophia 21 

Fig.    5. — Chondrodystrophia 22 

Fig.    6.— Cretinism 23 

Fig.    7.— Dyspituitarism ...  23 

Fig.    S. — Case  of  Siamese  Twins .24 

Fig.    9.— Triplets 25 

Fig.  10.— Chart  Showing  Growth  in  Late  Fetal  Weeks  ...  33 

Fig.  11.— Changes  in  Body  Proportions  in  Fetal  Life     .      .  36 
Fig.  12. — Chart  of  Weight  and  Surface  Area        ....                       .48 

Fig.  13.— Dermatograph 49 

Fig.  11.— Position  of  Stomach  in  Sixteen  Weeks'  Fetus 53 

Fig.  15. — Position  of  Stomach  in  Full-term  Infant    .      .  ....  54 

Fig.  16.— Roentgenogram  of  Stomach  Immediately  After  Feeding  55 

Fig.  17.— Section  Through  Esophagus  (Thirty-two  Weeks)  .      .  56 

Fig.  18.— Section  Through  Middle  of  Fundus  of  Stomach  (Twenty-two 

Weeks) 56 

Fig.  19.— Section  Through  Pyloric  End  of  Stomach  (Twenty-four  Weeks)  57 

Fig.  20.— Section  Through  Pyloric  End  of  Stomach  (Twenty-eight  Weeks)  57 

Fig.  21. — Stomach  of  Twenty-four  Weeks'  Fetus 59 

Fig.  22.— Stomach  of  Twenty-six  Weeks'  Fetus 59 

Fig.  23.— Stomach  of  Twenty-eight  Weeks'  Fetus 59 

Fig.  24.— Stomach  of  Thirty-two  Weeks'  Fetus 60 

Fig.  25.— Stomach  of  Thirty-six  Weeks'  Fetus 60 

Fig.  26.— Stomach  of  Forty  Weeks' Fetus 61 

Fig.  27.— Embryologic  Eye  Section 75 

Fig.  28. — Embryologies!  Section  of  Temporal  Bone 76 

Fig.  29.  —  Development  of  Centers  in  Weeks 78 

Figs.  30  and  31.— Fetus  at  Seven  Weeks 79 

Figs.  32  and  33.— Fetus  at  Eight  Weeks 80 

Figs.  34  and  35.— Fetus  at  Ten  Weeks 84 

Fig.  36. — Photograph  (a)  and  roentgenogram  (b)  of  transparent  speci- 
mens of  fetus  at  ten  weeks.     One-half  actual  size  ....  85 

Figs.  37  and  38.— Fetus  at  Eleven  to  Twelve  Weeks 86 

Figs.  39  and  40.— Fetus  at  Thirteen  to  Sixteen  Weeks 87 

Fig.  41. — Ossification  Centers,  Eleven  to  Twelve,  and  Thirteen  to  Sixteen 

Weeks 88 

Fig.  42. — Cross-section,  Arm  of  Fetus,  Twenty-two  Weeks       ....  89 

Fig.  43. — Cross-section,  Forearm  of  Fetus,  Twenty-two  Weeks      ...  90 

Figs.  44  and  45.— Fetus  at  Seventeen  to  Twenty  Weeks      ...  91 

Figs.  46  and  47.— Fetus  at  Twenty-five  to  Twenty-eight  Weeks    .  92 
Fig.  48. — Skull  of  Fetuses,  Seventeen  to  Twenty  Weeks,  and  Twenty-five 

to  Twenty-eight  Weeks 93 

Figs.  49  and  50. — Fetus  at  Twenty-nine  to  Thirty-two  Weeks.     .     .  94 
Figs.  51  and  52.— Fetus  at  Thirty-three  to  Thirty-six  Weeks    .  95 
FlG.  53.  — Skull  of  Fetuses,  Twenty-nine  to  Thirty-two  Weeks,  and  Thirty- 
three  to  Thirty-six  Weeks 97 


X  LIST  OF  ILLUSTRATIONS 

PAGE 

Fig.  54.— Good  Secreting  Breast 115 

Fig.  55. — Type  of  Breast  to  be  Avoided  in  Selecting  Wet-nurse     .      .      .      115 

Figs.  56  and  57. — Uniform  of  Wet-nurse 120 

Fig.  58.— Proper  Method  of  Holding  Baby  During  Nursing      .  .     125 

Fig.  59.— Premature  Infant,  Nursing 126 

Fig.  60.— Breast  Pump 127 

Figs.  61  and  62.— Direct  Expression  of  Breast  Milk       ....  .      128 

Fig.  63.— Floor  Plan  of  Infant  Ward 136 

Fig.  64.— Hospital  Bath  Room 138 

Fig.  65.— Divan  Bath      .      .  138 

Fig.  66. — Electrically  Warmed  Dressing  Table 139 

Fig.  67. — Unhealed  Dressing  Table 139 

Fig.  68. — Scale  for  Weighing  Infant 140 

Fig.  69. — Thermometer  (Adjustable) 140 

Fig.  70.— Hygrometer 140 

Fig.  71.— Table  of  Relative  Humidity 141 

Fig.  72.— Milk  Station 141 

Fig.  73.— Portable  Bath  Basin  .      .  142 

Fig.  74. — Individual  Bed  for  Infected  Cases 142 

Fig.  75. — Emergency  Robe 144 

Fig.  76. — Emergency  Robe  on  Infant 145 

Fig.  77.— Woolen  Bag  with  Hood 154 

Figs.  78  and  79.— Undershirt  and  Overshirt 155 

Fig.  80.— Pinning  Skirt 156 

Fig.  81.— Bib 156 

Fig.  82.— Pattern  for  Shirts '. 157 

Figs.  83  and  84.— Dressing  the  Babv 158 

Figs.  85  to  91.— Hospital  Records 160  to  165 

Fig.  92. — Special  Bath  Room  for  Private  Home 166 

Fig.  93. — Plan  for  Stations  in  Private  Home 167 

Fig.  94. — Feeding  Premature  Infant 172 

Fig.  95.— Fruit  Spoon  for  Mouth  Feeding 173 

Fig.  96. — Medicine  Dropper  for  Use  in  Feeding 173 

Fig.  97.— Nursing  Bottles 173 

Fig.  98.— Breck  Feeder 174 

Fig.  99. — Utensils  for^Catheter  Feeding 175 

Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 


00. — Catheter  Feeding  (Roentgenograph) 176 

01.— Catheter  Feeding 177 

02. — Baby  Juanita,  Weight  1070  grams 185 

03. — Baby  Juanita,  Weight  and  Food  Curves 185 

04.— Baby  Silvis  B 186 

05.— Baby  Silvis  B.,  Weight  and  Food  Curves 186 

06.— Baby  Allen  B.,  1135  grams 187 

07.— Baby  Allen  B.,  Weight  and  Food  Curves 187 

08.— Baby  Peggy,  1185  Grams 188 

09.— Baby  Peggy,  2155  Grams 188 

10. — Babv  Peggv,  Weight  and  Food  Curves 189 

11.— Baby  Grace  A.,  1180  Grams 189 

12.— Baby  Grace  A.,  1875  Grams 190 

13.— Baby  Grace  A.,  Weight  and  Food  Curves 190 

14.— Baby  Peter  P.,  1220  Grams 191 

15.— Baby  Peter  P.,  Weight  and  Food  Curves 191 

16.— Babv  Ethna  H 192 

17.— Baby  Ethna  H.,  Weight  and  Food  Curves 193 

18.— Joseph  and  Edward  R.,  Twins,  1360  and  1190  Grams  ...  193 

19.— Joseph  and  Edward  R.,  Weight  and  Food  Curves    ....  194 

20.— Babv  Grace  B.,  1395  Grams 195 

21.— Baby  Grace  B.,  Weight  and  Food  Curves 195 

22.— Baby  Glenn 196 

23.— Baby  Glenn,  One  Hundred  and  Eight  Days  Old      ....  196 

24.— Baby  Glenn,  Aged  Five  Years 197 


LIST  OF  ILLUSTRATIONS  xi 

PAGE 

25.— Baby  Glenn,  Weight  and  Food  Curves 197 

26.— 'Baby  Ann  C,  Aged  Eighteen  Days 198 

27.— Baby  Ann  C,  Aged  One  Hundred  and  Thirty-six  Days      .      .  198 
28.— Baby  Ann  C,  Weight  and  Food  Curves  .     .     .     .     .     .     .199 

29. — Utensils  for  Artificial  Feeding 200 

30.— Warm  Tub  Incubator ...  206 

31. — Modified  Warm  Incubator 207 

32.— Tarnier  Incubator .  207 

33.— Finkelstein's  Incubator 209 

34.— Reinaeh  Heated  Bed 210 

35.— Rommel  Incubator L'll 

36. — Lyon-type  Incubator.     Couney  Model 212 

27. — Lyon-type  Incubator.     De  Lee  Model 213 

38.— Moll  Heated  Bed 214 

39.— Hess  Water-jacketed  Infant  Bed 214 

40. — Cross-section  Hess  Bed  (Diagram) 215 

41. — Cross-section  Hess  Bed  (Direction  Air  Currents)      ....  216 
42. — Variation  in  Weight  Curyes  of  Infant  While  In  and  Out  of 

Heated    Bed 220 

43. — Copper  Receptacle  Containing  Pads 224 

44. — Incubator  Room,  Escherich-Pfaundler  System 227 

45. — Heated  Room,  University  of  California 228 

46. — Sloan  Hospital  Incubator 229 

47. — Obstetrical  Bag  Designed  for  Transportation 230 

48. — De  Lee  Transportation  Incubator 231 

149  and  150. — De  Lee  Incubator,  Outer  and  Inner  Case             .      .  232 

51. — Thymus  Gland  Causing  Death 248 

52. — Congenital  Atelectasis -!•">_' 

53. — Diffuse  Congenital  Atelectasis       •. 255 

54. — Incomplete  Diaphragmatic  Hernia 256 

55. — Incomplete  Diaphragmatic  Hernia 257 

56. — Application  in  Inguinal  Hernia 295 

57. — Inguinal  Herm'a  Bandage 296 

58. — Pad  for  L'se  in  Hernia  Bandage 296 

59. — Umbilical  Hernia  Bandage 297 

60. — Umbilical  Hernia  Bandage,  Cotton  Cigarette  in  Place  .      .      .  298 

61. — Umbilical  Hernia  Bandage,  Adhesive  Strap  in  Place    .      .      .  298 

162  and  163.— Pabv  P.  H.,  Megacephalus 304 

64.— Baby  P.  H.,  Weight  and  Food  Curves 305 

65. — Hydrocephalus 306 

66. — Oxvcephalus 307 

167  and  168.— Congenita]  Syphilis 322 

69. — Congenital  Syphilis 323 

70.— Osteochondritis  Syphilitica 324 

171  to  175.— Bone  Development  in  Syphilis 326  and  327 

76. — Erythroblastosis : 344 

177  and' 178.— Rickets 347  and  348 

79. — Spasmophilia 354 

80. — Fracture  of  Both  Forearms  in  Spasmophilia 359 

81.— Two  Greek  Triplets.  690  and  740  Grams 365 

182  and  183.— Two  Greek  Triplets,  Weight  and  Food  Curves    .      .  365 

84.— Infant  Born  at  Thirty-six  Weeks 383 

85.— Same  Child  Aged  Two  and  a  Half  Years 384 

86.— Same  Child,  Aged  Four  and  a  Half  Years 384 

87.— Infant   Born    at   Thirty-four   Weeks,  Complication     5 

Paraplegia 

88—  Same  Child,  Standing  Posture       .     . 385 

89. — Same  Child,  Showing  Results  Following  Tendon  Transplanta- 
tion          386 


INDEX  OF  TABLES. 


PAGE 

Brain  Weight 37 

Causes  of  Premature  Births 371 

Death,  Fetal  Ages  Factor  in 362 

Decreased  Mortality  with  Increased  Birth  Weight 363 

Food  Requirements  in  Calories,  1000  and  1500  Grams  in  Weight  .      .      .  181 

Humidity  Readings 141 

Infants  with  Birth  Weights  to  2500  Grams  in  First  Eight  Years    .  381 

Kidneys,  Weight        39 

Liver,  Weight 38 

Measurements  of  Assistance  in  Estimating  Viability 369 

Mortality  Statistics  in  Prematures 375 

Ossification  Centers,  Body 81 

Head 80 

Pelvic  Girdle  and  Lower  Extremities 83 

Vertebrae 82 

Outcome  in  Prematures,  as  Regards  Development 37 ^ 

Percentage  Saved  After  Induced  Labor 370 

Relation  Between  Birth  Weight  and  Length  Measurement        ....  30 

Mortality  and  Subnormal  Temperature 368 

Of  Body  Weight  to  Megacephalus 307 

Spleen,  Weight 39 

Temperature  on  Admission  and  Mortality  of  Premature  Infants    .      .  230 

Time  of  Occurrence  of  Megacephalus 308 

Umbilical  and  Inguinal  Hernia,  Occurrence  of 294 

Walking  and  Talking  Time  in  Prematures 382 


PREMATURE  AND  CONGENITALLY 
DISEASED  INFANTS. 


PART  I. 
ETIOLOGY-PHYSIOLOGY-PATHOLOGY. 


CHAPTER  I. 
DEFINITION. 


The  term  premature,  in  the  precise  meaning  of  the  word,  refers 
to  those  infants  born  before  the  end  of  the  fortieth  week  of  preg- 
nancy, but  in  common  usage  it  refers  only  to  those  infants  who 
have  undergone  a  gestation  period  of  two  hundred  and  sixty  days 
or  less,  and  so  it  may  be  understood  that  when  the  designation 
premature  is  used,  it  refers  to  those  infants  born  three  weeks  or 
more  before  the  usual  termination  of  pregnancy. 

There  is  another  class  of  infants  who  may  be  considered  in 
practically  the  same  category  as  the  prematures.  These  are  the 
weaklings,  infants  born  possibly  at  term,  or  nearly  so,  yet  who 
have  suffered  more  or  less  severely  during  their  intra-uterine 
existence  through  factors  which  interfered  with  their  nutrition  and 
consequently  their  development.  They  are  classed  as  congenitally 
diseased  or  debilitated. 

In  contrast  to  the  prematures  there  are  the  full-term  and  mature 
infants.  The  full-term  must  be  considered  that  one  who  is  born 
at  the  completion  of  the  normal  period  of  two  hundred  eighty  days 
of  pregnancy.  The  mature  infant  is  one  possessed  of  all  the  facul- 
ties for  extra-uterine  existence  and  may  be  born  before  or  at  the 
expiration  of  normal  gestation.  Thus  it  may  be  seen  that  the 
functional  and  not  the  anatomical  characteristics  should  decide 
maturity.  While  prematurity  pertains  to  time  and  congenital 
disease  or  debility  to  function,  the  prematures  do  not  need  to  be 
weaklings,  whereas  the  full-terms  may  show  evidence  of  congenital 
disease  or  debility. 

The  congenitally  diseased  are  usually  pale  in  appearance,  thin, 
underweight,  show  a  lack  of  cutaneous  turgor,  and  have  a  low 
2 


18  INTRODUCTION 

reactive  capacity,  suckle  and  drink  poorly  and  have  a  tendency 
to  restlessness,  abnormal  abdominal  distention  and  dyspeptic- 
stools.  Not  infrequently  this  class  of  infants  fails  to  gain  weight 
in  a  normal  manner  and,  therefore,  often  require  several  weeks  to 
regain  their  birth  weight.  This  indicates  functional  incapacity 
even  in  the  absence  of  demonstrable  organic  disease.  This  lack  of 
functional  development  varies  greatly  with  the  individuals. 

With  reference  to  this  class  Jaschke1  remarks  that  we  should  admit 
that  vital  debility  must  be  designated  as  a  congenital  functional 
deformity  which  manifests  itself  chiefly  in  a  deficient  resistance  or 
very  low  tolerance  to  the  conditions  and  variations  of  the  extra- 
uterine life.  The  debilitated  infants  react  on  one  hand  with 
symptoms  of  disease  toward  physiological  stimulus,  and  on  the 
other  hand  their  well-being  is  unfavorably  influenced  by  the  slight- 
est degree  of  over-  or  understimulation. 

Many  premature  infants,  not  only  have  been  born  before  full- 
term,  but  also  have  their  physical  development  retarded  by  intra- 
uterine disease  and  are  below  the  average  physical  development 
for  fetuses  of  a  similar  age.    . 

It  must  be  remembered  that  all  infants  born  before  the  end 
of  a  normal  term  are  born  before  the  end  of  a  full  intra-uterine 
pregnancy,  and  consequently  their  organs  are  not  fully  developed. 
As  a  result  they  show  certain  definite  body  weaknesses,  and  a  lack 
of  resistance  to  the  traumas  of  extra-uterine  life.  These  are  imma- 
ture even  though  fully  developed  for  their  fetal  age. 

This,  however,  is  only  a  relative  body  iveakness  in  the  absence  of 
inherited  constitutional  debility  and  malformations. 

It  is  also  a  fact  that  the  younger  the  fetus  when  leaving  the 
uterus,  the  greater  are  the  difficulties  to  be  overcome  in  the  carry- 
ing out  of  the  required  body  functions  necessary  to  life  and, 
therefore,  the  lower  its  vitality. 

In  a  study  of  premature  and  congenitally  debilitated  infants  at 
least  two  factors  in  the  life  history  of  the  fetus  must  be  considered: 

1.  The  term  of  its  intra-uterine  life. 

2.  The  state  of  its  functional  development  at  birth  as  evidenced 
by  the  presence  or  absence  of  inherited  disease. 

Congenital  debility  is  dependent  upon  constitutional  influences 
in  the  parents,  and  intercurrent  disease  during  the  term  of  preg- 
nancy. 

Notwithstanding  the  fact  that  both  of  the  above  factors  must 
be  given  the  most  careful  consideration,  practically,  in  most 
instances,  the  influence  of  either  factor  on  the  extra-uterine  life 
of  the  fetus  in  its  early  days  cannot  be  definitely  determined. 

1  Physiologie,  Pflege  unci  Ernahrung  des  Neugeborenen.     J.  F.  Bergman,  1917. 


CHAPTER  II. 

CLASSIFICATION. 

For  practical  clinical  purposes  the  group  of  infants  comprising 
the  premature  and  congenitally  debilitated  may  be  classified  as 
follows : 

1.  Premature  infants,  with  no  pathological  changes. 

2.  Premature  infants,  with  pathological  changes,  due  to: 

(a)  Constitutional  disease  and  chronic  infections  in  the  parents. 

(b)  Maternal  factors  influencing  the  fetal  nutrition,  such  as 
o\  erwork,  undernourishment  and  acute  illnesses  during  pregnancy. 

(c)  Local  conditions  in  the  mother. 

(d)  Multiple  pregnancies. 

(e)  Constitutional  defects  and  congenital  malformations  in  the 
fetus. 

(/)  Infants  born  to  parents  late  in  life. 

3.  Full-term  infants  with  pathological  changes  due  to  the  same 
causes  as  those  enumerated  under  2. 


ETIOLOGY. 

The  occurrence  of  premature  birth  depends  upon  many  causes, 
which  may  be  divided  into  those  resulting  in  the  expulsion  of  a 
healthy  premature,  and  those  which  have  a  damaging  effect  upon 
the  product  of  conception.  In  the  first  class  may  be  included 
various  injuries,  falls,  heavy  lifting,  overwork  or  other  physical 
exhaustion,  sudden  emotional  disturbances  and  premature  rupture 
of  the  membranes,  either  accidental  or  intentional,  occurring  in 
those  conditions  whose  existence  does  not  affect  the  nutrition  of 
the  ovum,  as  in  pelvic  and  spinal  deformity  in  the  mother,  placenta 
previa,  etc. 

Conditions  in  the  mother  requiring  operative  procedure  not 
involving  the  uterine  cavity  frequently  result  in  premature  labor 
either  through  shock  and  trauma,  resulting  from  operations,  as  for 
ovarian  conditions  and  uterine  fibroids,  or  infection  may  be  an 
added  danger  in  cholecystitis,  cholelithiasis,  appendicitis,  ileus  and 
renal  operations. 

The  cases  which  fall  within  the  second  category  all  react  to  a 


20 


CLASSIFICATION 


greater  or  lesser  degree  upon  the  fetus,  some  producing  only  momen- 
tary weakness,  as  the  milder  acute  infections,  others  causing  a 
weakened  physical  condition  as  a  result  of  their  long-continued 
action  upon  the  nutrition  and  development  of  the  fetus. 


Fig.  1. — Case  of  congenital  goiter. 


Fig.  2. — Case  of  congenital  thymus  (atrophy  of  gland  following  two  exposures  to 

roentgen  ray). 


ETIOLOGY 


1\ 


<^ 

Mi 

"^      -%»• 

w 

- 

i 

« 

i 

flH^ 

i 

Fig.  3.  —  Mongolian  idiot. 


Fig.  4. — Chondrodystrophia. 


22 


CLASSIFICATION 


The  most  frequent  causes  are  the  chronic  infections.  Syphilis 
plays  the  leading  role,  and  is  estimated  as  being  a  factor  in  from 
50  to  80  per  cent  of  all  cases  of  repeated  premature  expulsion  of  the 
fetus,  while  Lesage  and  Kouriansky1  state  that  syphilis  is  a  factor 
in  the  causation  of  congenital  debility  of  the  full-term  in  25  to  35  per 
cent.  If  the  luetic  infection  is  recent,  abortion  is  the  rule;  but  as 
the  infection  becomes  older,  the  succeeding  pregnancies  terminate 


Fig.  5. — Chondrodystrophia. 

later  and  later  until  a  living  child  with  or  without  manifestations 
of  the  disease  is  born,  usually  prematurely. 

Chronic  nephritis  is  one  of  the  most  frequent  causes  of  spon- 
taneous premature  labor,  and  the  offspring  of  these  mothers  are 
often  puny,  due,  either  to  the  systemic  effect  on  the  mother,  or 
resulting  from  impaired  nutrition  of  the  fetus  due  to  placental 


1  Congenital  Debility  and  Atrophy,  Nourrisson,  Paris,  July,  1919,  No.  4,  7,  193. 


ETIOLOGY 


23 


hemorrhages  and  infarcts.  Nephritis  in  the  mother  is  also  one 
of  the  most  frequent  indications  for  the  induction  of  premature 
labor. 


Fig.  6. — Cretinism. 

Pulmonary  tuberculosis  is  less  frequently  the  cause  of  premature 
labor,  but  the  children,  even  at  full-term,  are  often  small  and 
weak.  Tuberculosis  of  other  organs  and  tissues  influences  the  fetus 
in  proportion  to  the  nutritional  effect  upon  the  mother  or,  again 
when  involving  the  vertebral  column  or  hip-joints  may  by  their 


Fig.  7. — Dyspituitarism. 


resulting  deformities  require  premature  induction  of  labor.  Con- 
genital tuberculosis  is  very  rare,  but  does  occur.  In  the  majority  of 
cases,  not  the  disease  per  se,  but  the  predisposition  is  inherited. 


24 


CLASSIFICATION 


Premature  birth  occurs  in  .30  or  35  per  cent  of  the  cases  of  broken 
compensation  in  heart  disease.  The  premature  infants  are,  in 
these  cases,  often  imperfectly  nourished  as  a  result  of  the  poor 
aeration  of  the  mother's  blood.  Exophthalmic  goiter  is  occasion- 
ally the  cause  of  premature  emptying  of  the  uterus.  If  chronic 
dyspnea  exists,  as  a  result  of  laryngeal  or  tracheal  stenosis  from 
pressure,  the  development  of  the  fetus  will  necessarily  be  retarded. 


Fig.  8. — Case  of  Siamese  twins.     Thoracopagus  tetrabrachius  tetrapus.     (From  the 
service  of  Dr.  Ludwig  Simon,  Michael  Reese  Hospital,  Chicago.) 


Any  of  the  acute  infectious  diseases  may  be  responsible  for  the 
termination  of  pregnancy  before  the  end  of  term.  Pneumonia, 
influenza,  typhoid  fever,  malaria,  diphtheria,  scarlet  fever,  measles, 
small-pox,  Asiatic  cholera  and  bubonic  plague— all  have  a  dele- 
terious effect  on  the  continuance  of  pregnancy.  Premature  labor 
is  very  common  in  pneumonia  and  influenza,  being  more  frequent 
in  late  pregnancy. 

Of  local  conditions,  diseases  of  the  decidua  or  endometrium, 
gonorrheal  infection  and  malpositions  of  the  uterus  frequently 
result  in  premature  labor,  but  usually  before  the  fetus  is  viable. 
Anomalous  positions  of  the  fetus  in  the  uterus  may  be  responsible 
for  the  premature  expulsion  of  the  uterine  contents. 


ETIOLOGY 

The  occurrence  of  multiple  pregnanqj  is  a  fruitful  source  of 
premature  labor.  About  70  per  cent  of  twin  pregnancies  termi- 
nate prematurely  and  the  length  of  practically  all  triplet  and 
quadruplet  gestations  is  considerably  shortened  in  most  instances 
due  to  lack  of  room  in  the  uterine  cavity.  Miller's1  figures  are 
slightly  smaller.  He  states  that  of  3380  plural  births,  2040,  or 
00  per  cent,  were  premature,  and  had  a  body  weight  of  less  than 
2500  gm.,  and  a  length  under  45  cm.  Even  when  mature,  twins 
are  usually  small  and  of  low  body  weight.  This,  of  course,  is  even 
more  true  of  triple  pregnancies,  the  reserve  strength  possessed  by 
the  mother  not  being  sufficient  to  allow  three  fetuses  to  reach  their 
normal  development.  Again  in  the  presence  of  several  fetuses  the 
growth  may  proceed  unequally  so  that  one  may  be  born  with 
unimpaired  vitality,  and  the  others  with  greatly  diminished  strength 
(Fig.  9). 


Fig.  9. — Triplets. 

Faulty  nutrition  of  the  fetus,  such  as  is  found  in  maternal  over- 
work or  from  lack  of  sufficient  food,  as  well  as  that  due  to  wasting 
diseases,  the  blood  dyscrasias  (pernicious  anemia  and  leukemia) 
and  intoxication  from  alcohol  (acute  and  chronic),  phosphorus, 
arsenic,  mercury  or  lead  may— any  one  of  them— cause  either  an 
early  termination  of  pregnancy  or  so  serious  a  lowering  of  nutrition 
of  the  fetus  that  the  vitality  at  birth  may  be  greatly  impaired. 
In  addition,  congenital  malformations  in  the  fetus  sometimes  bring 
on  premature  birth.  In  diabetes  prematurity  is  not  infrequent, 
and  the  infants  may  show  glycosuria. 

Infants  born  to  parents  late  in  life  are  often  born  prematurely, 
perhaps  because  of  the  factor  of  undernourishment.     This  is  also 

1  Peculiarities  of  the  Disease  of  the  Premature  Infant,  Jahrb.  f.  Khlk.,  lssc>,25,  120. 


2G  CLASSIFICATION 

the  case  in  prematures  born  of  women  who  have  had  numerous 
pregnancies,  at  short  intervals. 

Finally,  habitual  miscarriage,  without  evident  cause,  resulting  in 
the  interruption  of  successive  pregnancies,  not  infrequently  at  about 
the  same  stage,  is  not  rare.  The  author  has  records  of  several  such 
women  without  a  history  of  syphilis  or  other  constitutional  disease, 
and  in  whom  uterine  deformity  is  not  demonstrable. 

The  frequency  of  premature  labors  varies  greatly  in  different 
clinics.  Rommel1  quotes  the  following  figures  from  various  clinics, 
noting  the  number  of  infants  under  2500  gm.  in  weight  and  below 
4o  cm.  in  length. 

Miller  .      .      .      .        5.0  per  cent 


Von  Winckel 
Fehling 
Budin  . 
Pinard 


13.3 

25.0 
10.7 
15.4 


Orphan  Asylum    . 

Moscow 

Maternity        .      .      . 

Munich 

Maternity 

Halle 

( 'Unique  Tarnier 

Paris 

"        Baudelocque 

Paris 

It  is  stated  that  the  percentage  of  premature  births  is  greater 
during  the  colder  months  of  the  year. 

1  Quoted  from  Pfaundler  and  Sehlossman  Handb.  f.  Kinderh.,  Leipzig,  1901. 


CHAPTER   I  I  1 
PHYSIOLOGY. 

CLINICAL  FEATURES. 

The  appearance  and  characteristics  of  the  healthy  premature 
child  vary  with  the  fetal  age  at  the  time  of  birth.  With  a  lengthen- 
ing of  the  period  of  gestation,  the  distinctive  characteristics  of 
the  fetus  become  less  and  less  marked  until  it  becomes  impossible 
to  differentiate  the  slightly  premature  from  the  full-term  infant. 
All  the  distinguishing  features  of  the  premature  may  also  be  found 
in  the  congenitally  diseased  full-term  infants,  and  as  there  may  be 
all  degrees  of  prematurity,  so  we  also  find  all  stages  of  development 
between  the  extremes  of  functional  and  anatomical  inferiority 
on  the  one  hand  and  the  normal  constitution  on  the  other.  Both 
the  premature  and  the  debilitated  infant  may  exhibit  the  following 
features  in  varying  degrees. 

The  body  is  usually  small  and  puny,  though  in  some  instances 
the  infant  may  be  of  a  considerable  size,  yet  with  a  very  imperfect 
development  of  its  internal  organs. 

The  weight  is  low,  varying  from  amounts  approximating  700  gm. 
(1£  lbs.)  to  2500  gm.  (5|  lbs.)  in  the  viable.  The  latter  figure 
may  be  exceeded  in  infants  nearing  maturity,  and  by  some  of 
the  full-term  weaklings,  but  will  serve  as  a  fair  maximum. 

The  skin  is  soft  and  usually  of  a  vivid  red  color.  The  epidermis 
is  thin  and  the  bloodvessels  are  easily  seen. 

The  skin  frequently  hangs  in  folds.  The  adipose  tissue  is  scant, 
the  features  are  angular  and  the  face  looks  old. 

Lanugo  is  plentiful,  especially  upon  the  extensor  surfaces  of  the 
extremities. 

The  skull  is  round  or  ovoid  in  contradistinction  to  the  usually 
markedly  dolichocephalic  skull  of  the  full-term  new-born.  The 
fontanelles  are  large  and  the  sutures  prominent. 

The  nose  exhibits  many  small  comedones.  The  ears  are  soft  and 
small  and  hug  the  skull. 

The  nails  have  scarcely  reached  the  ends  of  the  fingers  even  in 
the  larger  infants,  while  in  the  smaller  they  may  be  very  poorly 
developed. 

The  cry  is  feeble,  monotonous  and  whining. 

The  infant  lies  in  a  deep  sleep,  and  must  be  aroused  for  its  feed- 


28  PHYSIOLOGY 

rags.  Efforts  at  suction  are  weak  or  absent.  All  movements  afe 
slow,  functions  are  sluggish  and  the  child  shows  a  remarkable  degree 
of  muscular  inertia. 

The  temperature  has  a  very  decided  tendency  to  remain  below 
normal  and  is  inclined  to  be  irregular  in  character. 

The  urine  is  usually  scanty. 

The  bowels  are  sluggish  and  constipation  is  the  rule. 

Early  and  intense  jaundice  is  common. 

These  are  the  principal  findings  which  are  to  be  seen  on  super- 
ficial examination.  A  more  critical  review  of  these  various  char- 
acteristics follows.  It  must  be  remembered  that  any  of  these 
symptoms  may  vary  in  different  individuals  of  the  same  age, 
depending  upon  the  cause  of  prematurity,  and  upon  the  condition 
of  health  present  in  both  the  mother  and  the  child.  With  increas- 
ing age,  the  characteristics  become  less  marked,  until  the  picture 
eventually  merges  into  that  of  the  full-term  infant. 

The  determination  of  the  exact  age  of  the  infant  prematurely  born 
is  a  matter  of  considerable  difficulty.  The  information  furnished 
by  the  mother  as  to  the  time  of  her  last  menstrual  period,  or  as 
to  the  time  when  life  was  first  felt,  gives  an  entirely  insufficient 
approximation  of  the  probable  date  of  confinement,  and  errors  of 
a  month  or  even  more  are  not  rare.  In  institutions  for  found- 
lings all  data  is,  as  a  rule,  absent,  and  other  methods  for  deter- 
mining the  infant's  fetal  age  must  be  relied  upon.  The  weight 
of  the  infant  is  of  uncertain  value  also,  as  an  infant  of  1500  gm. 
weight  may  be  the  product  of  a  pregnancy  of  seven  months  in  a 
healthy  woman,  while  one  of  the  same  or  less  weight  may  be  the 
eighth-month  offspring  of  an  albuminuric  or  syphilitic  mother. 
The  body  measurements  also  vary  materially  with  the  individual. 
The  degree  of  development  of  the  osseous  system  is  of  great  value 
in  determining  the  anatomical  development,  and  indirectly  the 
condition  of  the  bones  acts  as  a  guide  to  physiological  development, 
even  though  they  do  not  give  absolute  data  as  to  age.  Body 
measurements  and  osseous  development  are  fully  discussed  later 
under  their  respective  headings. 

More  important  than  a  determination  of  the  approximate  term 
of  pregnancy  or  a  consideration  of  the  size  of  the  infant,  at  least 
in  those  infants  born  but  a  few  weeks  before  the  natural  termination 
of  the  period,  is  a  history  of  syphilis,  tuberculosis,  traumata,  or 
other  causes,  operating  in  the  mother  and  responsible  for  the  early 
emptying  of  the  uterus. 

His1  gives  the  following  description  of  the  developmental  features 
of  the  fetus  at  varying  ages: 

1  Anatomie  menschlicher  Embryonen,  11,  Leipzig,  1882. 


BODY  WEIGHT  AND  OTHER  MEASUREMENTS  29 

Fifth  Lunar  Month  (112  to  140  days).— Head  about  the  size  of 
hen's  egg;  the  skin  is  red  and  shows  some  fat  deposit.  The  scalp 
shows  indications  of  hair,  the  body  is  covered  with  lanugo,  (lie 
nails  can  be  distinguished,  the  eyelids  remain  closed.  The  fetus 
rarely  lives  over  five  to  ten  minutes,  making  feeble  attempts  at 
respiration.     The  heart-beats  may  be  strong. 

Sixth  Lunar  Month  (140  to  1G8  days).— The  body  shows  increased 
fat  deposits,  though  still  lean,  the  skin  being  wrinkled.  The  eye- 
lids are  separated  and  eyebrows  and  -lashes  may  be  seen.  The 
infant  may  live  for  several  hours.  The  respiratory  and  digestive 
organs  are  underdeveloped,  respirations  being  superficial  and 
digestion  practically  impossible. 

Seventh  Lunar  Month  (168  to  196  days).— The  infant  has  an 
aged  appearance  but  the  wrinkles  are  filling  out.  The  eyes  arc 
open.  The  cry  is  a  weak  whine  or  grunt.  Few  of  these  infants 
born  during  the  twenty-fifth  and  twenty-sixth  weeks  survive,  and 
when  they  do  are  usually  hydrocephalic,  paralytic  and  dwarfed. 
Those  of  the  twenty-seventh  and  twenty-eighth  weeks  are  far 
more  promising. 

Eighth  Lunar  Month  (196  to  224  days).— The  infant  is  beginning 
to  fill  out,  many  of  the  wrinkles  having  disappeared.  The  bones 
of  the  head  are  soft  and  flexible.  Ossification  begins  in  the  lower 
epiphysis  of  the  femur.  The  testicles  are  often  in  the  scrotum. 
The  cry  is  stronger,  though  it  may  still  be  very  weak.  Under 
proper  conditions  many  of  these  infants  survive. 

Ninth  Lunar  Month  (224  to  252  days).— Panniculus  adiposus 
develops.  The  wrinkles  smooth  out  and  the  limbs  become  rounded. 
The  lanugo  begins  to  disappear,  and  the  nails  are  at  the  tips  of 
the  fingers.  Respiratory,  circulatory  and  digestive  organs  are 
capable  of  carrying  on  the  body  functions. 

Tenth  Lunar  Month  (252  to  280  days).— The  general  body  func- 
tions improve  during  this  month  and  at  the  end  of  this  period 
development  is  complete. 

BODY  WEIGHT  AND  OTHER  MEASUREMENTS. 

Infants  born  at  full-term  weigh  on  the  average  from  ;!()()()  to 
3500  gm.  The  dividing  line  between  the  premature  and  full-term 
infant  has  been  generally  placed  at  2500  gm.  If  under  that  figure 
they  may  be  considered  below  par  as  far  as  concerns  the  strength 
and  ability  to  overcome  the  forces  which  assail  them  on  every 
hand.  The  weight  of  the  premature  varies  even  within  greater 
limits  than  that  of  the  full-term  infant,  and  as  one  may  sec  a  child 
below  2500  gm.,  so  also  there  are  prematures  with  a  weight  above 
this  limit. 


30 


PHYSIOLOGY 


The  weight  depends  upon  the  cause  of  the  premature  birth  and 
upon  the  age  of  the  child.  Those  born  of  mothers  afflicted  with 
nephritis,  tuberculosis,  or  other  wasting  diseases,  and  infants 
showing  active  syphilis,  are  usually  considerably  smaller  than  the 
same  aged  infants  of  healthy  parents.  Diseases  and  abnormal 
location  of  the  placenta  also  restrict  the  growth  of  the  fetus.  The 
infant  in  placenta  previa  is  often  undersized,  even  when  born  at 
term.     Multiparity  may  predispose  to  undersize. 

His,  in  a  comparison  of  the  fetal  weight  and  length  with  the 
age,  made  the  following  table: 

Weight. 
16  to  20  weeks  250  to    280  gms. 


20 

'  24      ' 

24 

'  28      ' 

28 

'  32      ' 

32 

'  36      ' 

36 

'  40      ' 

645 

'  1000     " 

1000 

'  1220     " 

1220 

'  1600     " 

1600 

'  2500     " 

2500 

'  3100     " 

length 

wi 

ill 

Length. 

17  to  26 

cm 

28   " 

34 

" 

35   " 

38 

" 

39   " 

43 

" 

46   " 

48 

n 

48   " 

50 

" 

THE   AVERAGE    LENGTHS    IN   CENTIMETERS    OF   NORMAL   FETUSES 
AS    GIVEN   BY   DIFFERENT   OBSERVERS. 


Lunar 

Schroe- 

months. 

Mall.2 

Von  Winckel.3 

De  Lee.1 

Lambert  z.5 

Ahlfeld.* 

der.7 

1st1 

0.25 

0.75-0.9 

2d 

0.55-  3.0 

0.9-2.5 

2.5 

3d 

4.1  -  9.8 

7-9 

7-9 

"     6-11 

4th 

11.7  -18.0 

10-17 

10-17 

11-17 

5th 

19.8  -25.0 

18-27 

17-26 

17-28 

6th 

26.8  -31.5 

28.34 

28-34 

26-37 

7th 

33.1  -37.1 

35-38 

38-35 

35-38 

36-40 

8th 

38.4  -42.5 

40-43 

43 

38-42 

40-43 

41.3 

9th 

43.6  -47.0 

46-48 

46-48 

42-45 

46-48 

44.6 

10th 

48.4  -50 

48-50 

48-50 

45-52 

48-50 

46.0 

The  weight  and  length  as  compared  to  the  fetal  age  is  shown 
in  the  following  table  from  Oberwarth,8  which  gives  the  average 
length  also: 


Fetal 

age. 

Weight. 

Length. 

26  weeks 

330  to  1041  gms. 

28.0  to  37.0  cm 

28      " 

995   "  1408      " 

36.3   "  37.5    " 

30      " 

797   "  1700      " 

33.1    "  41.3    " 

32      " 

1868  "  1964     " 

42.0   "  42.7    " 

34      " 

1286   "  2213      " 

39.0   "  47.0    " 

36      " 

2424   "  2700      " 

46.1    "  48.0    " 

1  The  length  for  the  first  two  months  represents  the  measurement  from  the  vertex 
to  the  buttocks;  all  the  other  measurements  are  from  vertex  to  sole. 

2  Manual  of  Human  Embryology,  1,  196. 

3  Handbuch  der  Geburtshiilfe,  1903,  Bergman,  Wiesbaden. 

4  The  Principles  and  Practice  of  Obstetrics,  Philadelphia:  W.  B.  Saunders  Co.,  2d 
Ed.,  1915. 

6  Development  of  the  Human  Skeleton  during  Fetal  Life,  Fortschr.  a.  d.  Geb.  d. 
Rontgenstrahlen,  Suppl.  I. 

6  Von  Winckel's  Handbuch  der  Geburtshiilfe,  I,  No.  1,  p.  290. 

7  Quoted  from  von  Winckel's  Handbuch  der  Geburtshiilfe. 

8  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1911,  7,  191. 


BODY  WEIGHT  AND  OTHER  MEASlfh'EM EXTS 


31 


These   compare   favorably   with   those   given    by   Ahlfeld    and 
Hecker.1 


Fetal  age. 
27  weeks 
29  " 
31  " 
33  " 
35  " 
37       " 


Weight. 

1140  gms. 

1575  " 

1975  " 

2100  " 

2750  " 

2875  " 


I, cunt  h. 
36.3  cm. 
39  6 
42.7 
43.9 
47.3 

l.s.ij 


Potel  and  Halm's2  figures  do  not  include  the  length. 


Fetal  age. 

Weight. 

27  weeks 

995  to  1146  gms. 

29      " 

1540  "  1700     " 

31      " 

1881   "  1964     " 

33      " 

2150   "  2213      " 

35      " 

2400   "  2700      " 

The  following  small  group  taken  from  my  cases  give  the  age  of  the 
fetus  as  computed  from  the  date  of  the  last  menstruation.  That 
this  is  an  unreliable  method  may  be  recognized  by  noting  the 
variation  in  figures. in  Cases  2,  3,  11,  13,  14  and  15.  We  therefore, 
place  little  reliance  on  the  mother's  estimate  as  to  the  date  of 
conception. 


Fetal  age, 
weeks. 

Weight, 
gni. 

Length, 
cm. 

Diameters  of  head. 

O.  F. 

Bi.  P. 

Bi.  T. 

Oc.  M. 

S.  O.  B. 

1 

21 

700 

30.0 

7.5 

5.5 

4.5 

9.0 

7.5 

2 

22 

1015 

37.0 

7.5 

6.5 

6.0 

9.0 

7.5 

3 

27 

1690 

40.0 

9.0 

8.0 

6.5 

11.0 

7.5 

4 

29 

1449 

8.0 

7.0 

7.0 

8.0 

7.0 

5 

31 

1175 

37.5 

9.0 

7.0 

6.0 

11.0 

8.0 

6 

32 

1380 

34.0 

9.0 

8.0 

7.0 

11.0 

7.0 

7 

32 

2040 

45.0 

11.5 

8.5 

7.5 

13.0 

9.5 

S 

33 

1175 

44.0 

9.0 

7.0 

6.0 

li.o 

8.0 

9 

33 

2110 

45.0 

10.0 

8.0 

6.0 

12.0 

8.0 

10 

38 

3625 

50.0 

11.0 

9.5 

8.0 

13.25 

9.5 

11 

39 

1610 

41.5 

10.0 

7.75 

6.25 

11.75 

8  -  :> 

12 

39 

3260 

49.0 

11.5 

9 . 5 

8.5 

13.5 

9.75 

13 

40 

1370 

38.0 

9.0 

7.0 

6.0 

10.0 

8.0 

14 

41 

1570 

35.0 

11.0 

8.0 

7.5 

11.5 

7.0 

15 

41 

1810 

38.5 

10.0 

8.0 

7.5 

12.5 

8.5 

In  contrast  with  these  measurements  of  the  diameters  of  the 
head  in  prematures,  the  average  measurements  of  the  skull  in  a 
mature  new  born  are  noted  as  follows  by  Schauta.3 

1  Arch.  f.  Gynak.,  1872,  2.     Quoted  from  Pfaundler  and  Schlossman,  Leipsig,  1901. 

2  Do  l'accroissement  en  poids  des  enfants  nes  avant  termc.     These,  Paris,  1895. 

3  F.  Lehr.  d.  ges.  Gyn.,  2.  AufL,  Leipzig  u.  Wien,  1897. 


32  PHYSIOLOGY 

1.  Diameter  suboccipito-bregmaticus  (from  the  posterior  edge  of 
the  great  occipital  foramen  to  the  anterior  angle  of  the  great  fon- 
tanelle),  9  cm. 

2.  Diameter  fronto-occipitalis  (from  glabella  to  the  occipital 
protuberance),  11  cm. 

3.  Diameter  mento-occipitalis  (from  the  point  of  the  chin  to  the 
farthest  point  of  the  occiput),  13  cm. 

4.  Diameter  verticalis  (from  the  vertex  to  the  base  of  the  skull), 
9.5  cm. 

5.  Diameter  biparietalis  (between  the  parietal  tuberosities),  9  cm. 

6.  Diameter  bitemporalis  (between  the  farthest  point  of  both 
coronary  sutures),  8  cm. 

Parents  short  in  stature  or  small  in  build  may  have  children 
who  do  not  weigh  over  2000  gm.  or  measure  over  45  cm.  in  length, 
and  yet  who  are  neither  premature  nor  congenitally  weak. 

It  does  not  do  to  estimate  the  vitality  of  these  infants  from  a 
consideration  of  their  birth  weight.  Many  of  them  born  at  or 
near  term  have  a  normal  weight,  yet  they  do  not  survive.  On 
the  other  hand,  infants  of  considerably  less  weight  may  present 
evidence  of  great  vitality,  a  lusty  cry  and  take  nourishment  with 
avidity.  According  to  our  experience  the  condition  of  the  turgor 
of  the  prematurely  born  infants  is  of  much  more  importance  than 
all  these.  Flabby  prematures  with  a  poor  turgor  and  a  poor  tonus 
are  usually  not  viable.  Prematures  with  a  good  turgor  and  a  good 
tonus  even  with  a  low  weight  commonly  survive. 

In  addition  to  the  variations  in  weight  and  length,  the  premature 
shows  variations  in  other  measurements. 

Other  Measurements  of  the  Fetus. — Yon  Winckel1  regards  the 
circumference  of  the  head  as  of  importance  for  the  diagnosis  of  the 
age  of  the  fetus  and  gives  the  following  figures: 


4th  month  . 

.      .      10-14  cm. 

Sth  month 

.      .      25-30  cm. 

5th  month  . 

.      .      13-18  cm. 

9th  month 

.       .      29-33  cm. 

6th  month  . 

19-24  cm. 

10th  month 

.      .     32-37  cm. 

7th  month  . 

.      .     23-28  cm. 

Ileiche2  reports  the  following  comparative  body  measurements: 


TABLE 

I. 

12  Children. 

Weight  800-1200  gm 

Group.  1. 

Min. 

Max. 

Average. 

Length  of  the  body 

.      34  cm. 

41.0  cm. 

37.4  cm. 

Circumference  of  chest 

.      21     " 

24.5    " 

22.5    " 

Circumference  of  head 

.      24     " 

29.5    " 

26.8    " 

i  Lehrb.  d.  Geb.,  Leipsig,  1889. 

2  The  Growth  of  the  Prematurely  Born  in  the  First  Months  of  Life,  Ztschr.  f. 
Kinderh.,  December,  1915,  13,  332. 


BODY  WEIGHT  AND  OTHER  MEASUREMENTS 


33 


table  i  (Continued) 

Group  2, 

26  Children. 
Mill.                               M:ix. 

Weight  1200-1500  gm 
Average. 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

37.0  cm.         45.0  cm. 
.     22.5    "            27.5    " 
.     26.0    "            31.0    " 

41.6  cm. 

24.8    " 
28.4    " 

Group  3. 

28  Children. 

Weight  1500-2000  gm 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

.     41  cm.             48.5  cm. 
.     25    "                32.5    " 
.     27    "                32.0    " 

44.2  cm. 

27.2  " 

30.3  " 

Group  4. 

22  Children. 

Weight  2000-2500  gm 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

.      41.5  cm.         49.0  cm. 
.      26.0    "            30.0    " 
.     29.0    "            33.5    " 

46.5  cm. 
28.4    " 
32.2    " 

GR. 

4000 

3800 

80 
3000 

3400  75 

3200  7() 

CM. 

3000        54 

05 
2800        52 

CO 

2600        50 

2400  55  48 

2200  -n  46 
aO 

2000        44 

45 
1800        42 

40 
1600        40 

1400  35  38 

1200  3Q  36 

1000        34 
25 

800        32 
20 

* 

7 

t 

& 

/ 

t 

A 

; 

^> 

S3* 

/ 

s 

V 

,, 

'"' 

/ 

?■ 

'" 

/ 

/  / 

// 

/ 

& 

(JM. 

38 
36 
34 
32 
30 
28 
20 
24 
22 
20 

'/ 

/<? 

i 

/ 

r- 

,'/ 

r 

_„ 

.-' 

-© 

ll 

/ 

,*' 

.  - 

,o 

1, 
II 

/ 
/ 

/ 

^ 

'* 

if 

/ 

Y 

tr' 

* 

1 

'    / 

P 

f 

- 

1 

/ 

> 

'(/ 

/ 

j- 

i) 

/, 

if 

.y 

- 

/ 

/, 

// 

/// 

& 

A 

7 

uJy 

600        30 

25    26    27   28    29    30    31 
WEEKS 

32   33  31   35 

30   37    38    39    40    41    42   43   14    45 

3 — o 

-RC 

>M 

j\ 

E 

-IT 

ER 

\T\ 

IRE 

Fig.  10. — Curves  showing  growth  in  weight,  length,  head  and  chest  measurements 
in  the  late  fetal  weeks  and  first  weeks  after  maturity.     (Reiche.) 

3 


34 


PHYSIOLOGY 


These  figures  show  a  gradual  and  steady  increase  of  the  weight 
and  the  chest  and  head  measurements,  up  to  the  time  of  maturity, 
when  they  should  average  3200  gm.  in  weight,  50.5  cm.  in  length, 
with  a  chest  circumference  of  32.9  to  33.8  cm.  and  a  head  circum- 
ference of  34.5  cm. 

We  see  in  the  eighth  to  the  tenth  month  an  abrupt  rise  of  the 
curve  of  chest  circumference,  the  curve  flattening  somewhat  soon 
after  birth.  This  increase  in  the  circumference  of  the  chest  in 
the  last  fetal  months  is  considerably  higher  than  that  of  a  mature 
child  during  the  first  months  after  birth.  In  the  latter  the  cir- 
cumference of  the  chest  increases  from  32.5  to  37.2  at  the  end 
of  the  third  month  to  41  at  the  end  of  the  sixth  month,  there- 
fore in  the  first  six  months  of  life  approximately  about  as  much  as 
in  the  last  three  fetal  months. 

In  the  curve  of  the  growth  of  the  skull  the  flattening  appears 
even  somewhat  earlier.  The  ratio,  however,  between  the  growth 
of  the  skull  in  the  last  three  fetal  months  and  that  in  the  first 
six  months  of  life  is  the  same  as  in  the  circumference  of  the  chest. 
Also  the  circumference  of  the  head  grows  absolutely  and  relatively 
considerably  more  in  the  last  fetal  months  than  in  the  first  six 
months  of  life. 

A  proof  for  the  correctness  of  these  figures  Reiche1  finds  in 
the  fact  that  the  corresponding  figures  are  considerably  lower  in 
children  who  die  shortly  after  birth.  They  are  premature  weak- 
lings whose  intra-uterine  development  in  spite  of  sufficient  body 
weight  did  not  attain  such  a  degree  that  it  might  be  completed  in 
the  extra-uterine  life. 

The  corresponding  figures  are,  as  follows: 


Group  1. 

7  Children. 
Min.                          Max. 

Weight  800-1200  gm. 
Average. 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

.      34.0  cm.         38.5  cm. 
.      18.0    "            23.5    " 
.      21.0    "            27.5    " 

37.0  cm. 
20.6    " 
25.0    " 

Group  2. 

9  Children. 

Weight  1200-1500  gin. 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

.      39.0  cm.         42.0  cm. 
.      21.0    "            27.0    " 
.      26.0    "            31.0    " 

40.1  cm. 
23.8    " 
28.8    " 

Group  3. 

5  Children. 

Weight  1500-2000  gm. 

Length  of  the  body 
Circumference  of  chest 
Circumference  of  head 

41 .5  cm.         47.0  cm. 
.      25.0    "            27.5    " 
.     28.0    "            31.0    " 

43.6  cm. 
25.9    " 
29.6    " 

From  these  figures  Reiche2  concludes  that  in  premature  weak- 
lings the  length  of  the  body  does  not  vary  greatly  from  that  of 

1  The  Growth  of  the  Prematurely  Born  in  the  First  Months  of  life,  Zeitschr.  f. 
Kinderh.,  December,  1915,  13,  332. 

2  Ztschr.  f.  Kinderh.,  1915,  13,  349. 


BODY  WEIGHT  AND  OTHER  MEASUREMENTS 


35 


healthy  children,  but  on  the  other  hand  the  measurements  of  the 
circumference  of  the  chest  and  of  the  circumference  of  the  head 

are  considerably  smaller. 

Ylppo1  recently  studied  the  relation  of  the  chest  circumference 
to  that  of  the  head  in  prematures  and  full-term  infants.  He  found 
that  at  birth  the  circumference  of  the  head  is  greater  than  that  of 
the  chest,  and  the  greater  the  prematurity  the  more  marked  is  the 
relative  disproportion  between  the  head  and  chest  circumferences. 
These  facts  are  borne  out  by  his  table: 


Hreast 

Weight  of  infants, 
Grams. 

Number. 

Circumference 
of  head. 

Circumference 
of  chest. 

cumference, 
per  cent  of 
bead  circum- 
ference. 

Under  1000        .... 

16 

25.0 

20.8 

83.2 

1001-1500       .... 

78 

31.8 

24.5 

77.0 

1501-2000       .... 

75 

30.0 

26.3 

87.7 

2001-2500       .... 

74 

32.3 

29.5 

91.3 

New  born 

3000-3500       .... 

100 

33.5 

31.0 

92.5 

In  comparison  with  the 
the  conclusions  drawn  by 
tabulations  compiled  by 
infant. 


preceding  tables  on  prematures  we  note 
von  Reuss2  from  his  own  work  and  the 
Weissenberg3  on  the  mature  new-born 


Boys. 

Girls. 

Body  measurement. 

Min. 

Max. 

Average. 

Min. 

Max. 

Average 

Body  length    . 

47.5 

54.0 

50.8 

43.5 

53.0 

50.0 

Span  of  arms 

45.0 

52.0 

48.6 

42.0 

52.0 

48.0 

Vertex-shoulder   . 

11.5 

13.5 

12.4 

10.5 

13.5 

12.1 

Sitting-height 

31.2 

36.5 

33.8 

30.0 

36.4 

33.3 

Breadth  of  shoulders 

9.0 

12.2 

10.7 

9.0 

12.0 

10.4 

Breadth  of  hips    . 

7.0 

8.7 

.     7.8 

6.8 

8.3 

7.7 

Circumference  of  head 

30.5 

35.5 

32.7 

29.0 

35.0 

32  6 

Girth  of  chest 

25.5 

32.0 

28.2 

25.0 

32.0 

28  5 

Length  of  trunk 

19.5 

24.0 

21.4 

19.0 

24.0 

_'  1   'J 

Length  of  arni 

19.5 

23.5 

21.4 

18.5 

22.5 

21.0 

Length  of  leg 

18.0 

22.2 

20.5 

17.0 

21.8 

20.3 

Length  of  hand    . 

5.8 

7.0 

6.4 

5.8 

7.5 

6.4 

Length  of  foot 

7.3 

8.3 

7.8 

6.5 

8.3 

7.8 

The  peculiarities  of  the  proportions  of  the  body  characteristic 
of  the  full-term  new  born  consist  therefore  of  the  following:  Not 
only  the  sitting  height,  but  also  the  height  of  the  trunk  proper  is 
greater  than  the  leg.     The  length  of  the  trunk  proper  is  greater 


1  Pathologisch-anatomische  Studien  bei  Friihgcburten,  Ztschr.  f.  Kinderh.,  March 
25,   1919,   Orig.  Bd.  20. 

2  Die  Krankheiten  des  Neugeborenen,  Julius  Springer,  1914. 

3  Die  Korperproportionen  des  Neugeborenen,  Jahr.  f.  Kinderh.,  1906,  64,  S39. 


36 


PHYSIOLOGY 


than  that  of  the  arm.  The  arm  is  longer  than  the  leg.  The  cir- 
cumference of  the  head  is  usually  greater  than  that  of  the  chest. 
Occasionally  the  circumference  of  the  head  and  chest  are  equal;  in 
strongly  built  infants  the  circumference  of  the  chest  often  exceeds 
that  of  the  head.  The  body  length  approximates  47  to  54  cm.  and 
errors  in  statements  of  length  result  because  of  the  lack  of  considera- 
tion for  the  deformity  of  the  skull  and  caput  succedaneum  (von 
Reuss1)- 

Jaschke,2  in  a  recent  study  of  the  premature  and  debilitated 
child,  came  to  the  conclusion  that  there  was  less  variability  in 


n.H. 


B.H. 


B.H. 


ML. 


Second  Month       Fifth  Month      Tenth  Month 


Fig.  11. — Changes  in  body  proportions  in  fetal  life.     B.H.,  Body  height;  M.L., 

Midline. 


certain  relations  between  measurements  of  the  body  than  was  com- 
monly thought.  "In  immature  infants  the  fronto-occipital  cir- 
cumference of  the  head  always  is  greater  than  the  circumference 
of  the  shoulders  (Frank  and  others),  while  in  mature  infants  the 
opposite  is  true;  also  the  proportion  between  the  height  of  the 
head  and  the  height  of  the  body  (Stratz)  is  disturbed  since  the 
height  of  the  head  is  greater  than  one-fourth  of  the  length  of  the 
body;    this  is  due  especially  to  relatively  shorter  legs"  (Fig.  11). 

1  Die  Krankheiten  des  Neugeborenen,  Julius  Springer,  1914. 

2  Physiologie,  Pflege  und  Ernahrung  des  Neugeborenen,  Wiesbaden,  1917. 


INTERNAL  ORGANS 


37 


INTERNAL  ORGANS. 

Gundobin1,  studying  the  average  weight  of  the  inner  organs  of 
the  mature  new  born  in  grams,  noted  the  following: 

Brain 389-354.5 

Heart 17.24-16.5 

Lungs 57  (Lt.  25;  Rt.  32) 

Liver 120-130 

Pancreas 2.63 

Spleen 7.2 

Kidneys 11-12 

Suprarenals 2.5 

Testicles 0.2 

Epididymes 0.12 

Ovaries 0.2 

Thyroid 1.6  (Max.  2.8;  Min.  1.3) 

Thymus 11.7 

In  contrast  with  these  figures,  we  may  quote  from  the  anatomical 
studies  of  Ylppo  on  premature  infants. 

BRAIN  WEIGHT  OF  INFANTS    (YLPPO).2 


Number  of 
cases. 

Boys. 

Age. 

Average  weight  in 

grams. 

Of  body. 

Of  entire  brain. 

Ratio  of  brain  to 
body  weight. 

Fetus  of  eight  months 

3 

2440 

248 

1  toJlO 

Newly  born 

3 

2785 

389 

1  to.7.2 

1  month 

3 

3860 

517 

1  to.7.5 

5 

4400 

533 

1  to  8.2 

3                   

5 

4480 

555 

1  to  8.1 

4       "           

5 

4890 

568 

1  to  8.6 

5                   

5 

5614 

632 

1  to  8.9 

6       "           

5 

6035 

668 

1  to  9.0 

7       "          

3 

6560 

702 

1  to  9.3 

8       "          

3 

6460 

768 

1  to  8.4 

Ylppo  found  several  instances  in  which  the  large  brain  weight 
seemed  to  be  out  of  proportion  to  the  figures  of  other  observers. 
His  studies  led  him  to  believe  that  the  brain  of  the  premature 
(even  the  smallest)  grows  at  the  same  rate  as  if  the  fetus  were  in 
utero  and  that  it  develops  in  extra-uterine  life  after  certain  given 
laws  of  Nature;  thus,  the  small  body  weight  having  relatively 
little  to  do  with  the  brain.  In  these  cases  of  marked  disproportion 
he  found  that  when  one  compares  the  absolute  age  of  the  prema- 

1  Quoted  from  von  Reuss:  Krankheiten  der  Neugeborenen,  Julius  Springer,  Berlin, 
1914. 

2  Pathologisch-anatomische  Studien  bei  Fruhgeburten,  Ztschr.  f.  Kinderh.,  .March 
25,  1919,  Orig.  Bd.  20,  212. 


3&  PHYSIOLOGY 

ture,  from  the  time  of  conception,  with  that  of  a  normal  infant, 
it  is  seen  that  the  brain  weight  of  the  two  compare  favorably. 
His  conclusions  were  that  the  size  of  the  brain  has  nothing  to  do 
with  a  hydrocephalic  process,  since  it  is  not  explained  by  an  abnor- 
mal water  content,  and  that  the  "  megacephaly "  of  prematures  is 
a  physiological  process. 

Tonsils.— In  prematures  there  appears  at  the  site  of  the  palatine 
tonsils  only  one  or  two  small  cavities.  Only  after  four  to  five 
months  does  a  glandular  structure  appear. 

Thyroid  Gland. — This  is  very  small,  but  it  has  a  very  rich  blood 
supply.  In  one  case  of  a  seven-months  premature  Ylppo  observed 
an  enlargement  of  the  thyroid  (1.5  gm.):  weight  of  infant,  1270 
gm.;  length,  44  cm.  Microscopically  there  were  large  quantities 
of  colloid  in  the  center  of  the  follicles,  but  no  hemorrhages  or 
evidence  of  degenerative  changes. 

Thymus  Gland.— In  prematures  of  1000  to  2000  gm.  it  is  between 
1  and  3  gm.,  while  in  full-terms  it  may  be  as  much  as  20  gm. 
Gundobin1  estimated  it  in  prematures  of  similar  weight  as  on  the 
average  of  2.5  gm. 

Heart.— The  heart  on  the  average  is  from  0.5  to  0.75  per  cent 
of  the  body  weight  of  prematures.  In  those  from  900  to  1200  gm. 
Ylppo  found  that  the  weight  ranged  from  4.5  to  7  gm.  In  full- 
term  infants  and  those  with  a  longer  intra-uterine  growth  (of  the 
prematures),  the  relation  between  heart  and  body  weight  was 
found  to  remain  about  the  same  by  Lomer,  thus : 

4000  gm.  infant  —  27.6  gm.  heart  =  0.7  per  cent  body  weight. 
2-3000  gm.      "        -20.7  gin.      " 
1-2000  gm.      "        -  11.4  gm.      " 

The  ductus  Botalli  closes  more  slowly  and  later  in  prematures. 
On  the  average  blood  ceases  to  pass  through  after  the  end  of  the 
first  or  second  week  of  life. 

Liver.— The  liver  is  the  largest  of  the  internal  organs  of  the 
premature  body.  The  smaller  the  premature,  the  greater  is  the 
relative  size  of  the  liver. 

WEIGHT   OF   THE   LIVER   IN   PREMATURES    (YLPPO). 


Weight  of  infant, 
Grams. 


Number  of 
cases. 


Average  weight 
of  liver. 
Grams. 


Liver  weight, 
percentage  of 
body  weight. 


Under  1000 
1001-1500 
1501-2000 
2001-2500 


11 

12 

4 

3 


43.73 

53.17 

56.75 

102.33 


4.8 
4.3 
3.3 
4.5 


1  Die  Besonderheiten  des  Kindesalters,  Berlin,   1912. 


BODY  TEMPERATURE 


39 


With  the  increase  of  body  weight  the  liver  weight  slowly  increases. 
The  figures  for  the  group  of  1501  to  2000  gin.  are  too  small,  and 
are  based  only  on  four  observations.  The  weight  of  the  liver  in 
prematures  has  to  do  with  the  richness  of  its  blood  supply. 

Spleen.— The  spleen,  as  the  liver,  is  very  rich  in  blood. 

WEIGHT   OF  THE   SPLEEN    (yLPPo). 


Weight  of  infant. 
Grams. 

Number  of 

cases. 

Average  weight 

nl  spleen. 

Grams. 

Spleen  weight 

percentage  of 
body  weight. 

Under  1000 

1001-1500    

1501-2000    

2001-2500    

14 

12 

4 
8 

1.5 
2.8 

4.4 
7.2 

0.17 
0.21 
0.22 

0.28 

As  with  the  liver,  the  spleen  increases  in  size  with  increase  in  the 
body  weight. 

Kidneys.— The  ratio  between  the  weight  of  both  kidneys  and  the 
body  weight  is  greater  in  prematures  than  in  full-terms  and  older 
infants: 

WEIGHT   OF   KIDNEYS    (YLPPO). 


Weight  of  child. 
Grams. 

Number  of 
cases. 

Average  weight 

of  kidneys. 

Grams,  i 

Kidney  weight 
percentage  of 
body  weight. 

Under  1000          

1000-1500    

15 
17 

5.2 
8.9 

0.59 
0.76 

Gundobin  showed  that  in  full-terms  the  percentage  was  0.38  per 
cent. 

Vierordt1  showed  that  in  men  between  nineteen  and  twenty-five 
years  of  age  the  percentage  was  0.48  per  cent. 

The  embryonic  features  of  the  kidneys  are  very  marked.  The 
fetal  markings  disappear  fairly  rapidly.  In  one  case  of  a  sixth  to 
seventh  embryonic  month  premature  of  1000  gm.  birth  weight, 
the  fetal  markings  were  gone  after  five  to  seven  weeks  of  life 
(Ylppo). 

BODY  TEMPERATURE. 

During  the  intra-uterine  life  the  child  receives  gratis  the  material 
necessary  for  its  maintenance,  for  the  development  and  regenera- 
tion of  its  cells.  The  maternal  blood  stream  brings  to  the  level 
of  the  placenta  the  oxygen  and  other  substances  needful  for  its 

1  Gerhardts  Handbuch  d.  Kinderh.,  1881,  1,  1,  part  2,  p.  386. 


40  PHYSIOLOGY 

nutrition,  and  the  passing  of  these  foods  into  the  antenatal  circu- 
lation requires  no  effort  on  the  part  of  the  fetus  other  than  the 
cardiac  contractions.  From  birth  on,  however,  the  child  is  an 
independent  being  and  it  must  fight  that  it  may  live. 

The  upkeep  of  the  somatic  tissues  is  dependent  upon  the  func- 
tions of  the  respiratory  system  and  the  digestive  tract,  and  these 
activities  require  of  the  new-born  infant  an  expenditure  of  energy 
of  which  it  has  had  no  previous  experience.  Before  birth  the 
energy  resulting  from  intracellular  combustion  was  transformed 
into  that  amount  of  heat  necessary  to  the  performance  of  the 
new  cellulo-chemical  reactions  occurring  in  the  fetus.  After  birth 
a  much  greater  amount  of  energy  is  necessary  because  of  the  more 
extensive  reactions  taking  place  within  the  tissues  and  because  of 
the  appearance  of  motion.  Increased  metabolism  is,  therefore, 
necessary  to  the  accomplishment  of  the  digestive  and  respiratory 
functions  and  to  enable  the  infant  to  fight  against  external  physical 
agents,  principally  cold. 

Cause  and  Nature  of  Hypothermia.— Heat  regulation  is  one  of  the 
least  developed  functions  of  the  premature  infants,  their  body 
temperature  showing  marked  fluctuation  with  a  tendency  to  hypo- 
thermia.    This  is  due  to  several  factors: 

1.  Faulty  Heat  Regulation  Due  to  Lack  of  Development  on  the 
Part  of  the  Nervous  System.— It  is  possible  to  imagine  that  in  a 
premature  infant  where  the  development  of  the  brain  is  still  going 
on,  and  the  separation  into  the  white  and  gray  matter  has  not  been 
completed,  that  the  nervous  system  is  not  sufficiently  matured  to 
function  normally. 

2.  Loss  of  Heat  Through  Radiation.— The  extent  of  the  heat 
loss  from  the  body  of  an  animal  by  conduction,  radiation,  evapora- 
tion from  the  skin  and  the  surface  of  the  lungs  is  determined  by 
the  extent  of  the  surface  and  by  the  thickness  of  the  ill-conducting 
subcutaneous  fatty  layer;  the  heat  loss,  therefore,  is  in  greater 
part  proportional  to  the  extent  of  the  surface  of  the  body.  In  a 
premature  infant  the  body  surface  is  relatively  greater  than  in  a 
full-weight  new  born,  since  the  size  of  the  body  is  absolutely  smaller. 
Wrinkled  skin  and  absence  of  the  fat  deposits  in  the  skin  are  respon- 
sible for  the  greater  loss  of  heat.  It  is  these  physical  conditions 
which  make  it  difficult  for  the  premature  to  retain  its  own  heat  and 
predispose  to  the  readiness  with  which  the  subnormal  temperature 
can  occur. 

3.  Insufficient  Oxygen  Combustion.— Due  to  a  poorly  developed 
respiratory  center  causing  asphyxia. 

Babak1  found  that  the  lower  the  temperature  in  the  respiratory 

1  Ueber  die  Wiirmeregulation  der  Neugeborenen,  Pflugers  Arch.,  1902,  89,  154. 


THE  GROWTH  OF  THE  PREMATURE  41 

chamber,  the  greater  the  consumption  of  oxygen,  this  correspond- 
ing to  the  irradiation  of  heat.  The  average  values  in  one  hour  per 
gram  of  body  weight  amounted  to: 

Temperature  in  chamber.  Consumption  of  Oi. 

Deg.  C.  cc. 

24.0  378 

23.2  562 

20.0  581 
19.9  632 

17.1  636 
12.9  739 
12.1  874 

From  the  results  of  this  experiment  it  is  clear  that  the  infant's 
organism  attempted  to  equalize  the  physical  minus  with  the  chemical 
plus.  But  in  spite  of  the  more  intensive  exchange  of  gases,  the 
body  temperature  was  sinking  with  a  low  external  temperature  and 
also  when  the  infant  was  insufficiently  covered.  The  increase  in 
oxidation  processes,  therefore,  was  not  sufficient  to  compensate 
for  the  increased  heat  radiation. 

4.  The  Circulation.— The  circulation  as  affected  by  its  nervous 
mechanism  and  weak  cardiac  action  is  another  important  factor. 

5.  Insufficient  Heat  Production  Due  to  Lack  of  Food  or  Improper 
Metabolism.— This  cause  of  hypothermia  is  of  minor  importance  in 
the  premature  infant  which  is  fed  a  sufficient  quantity  of  breast 
milk  and  shows  ability  to  assimilate  the  same.  As  the  sucking- 
centers  are  too  poorly  developed  to  enable  the  infant  to  obtain 
sufficient  nourishment,  most  of  these  infants  cannot  be  trusted 
to  their  own  resources  in  obtaining  their  food. 

A  careful  consideration  of  all  of  the  factors  tending  to  hypo- 
thermia make  it  evident  that  we  cannot  depend  on  an  equalization 
of  the  heat  loss  from  the  body  surface  by  the  internal  production 
of  heat,  and  therefore  in  order  to  maintain  a  uniform  temperature 
it  becomes  necessary  to  assist  the  infant  by  giving  it  an  artificial 
environment  of  good  air  sufficiently  heated  to  maintain  a  normal 
body  temperature. 

THE  GROWTH  OF  THE  PREMATURE. 

Initial  Weight  Losses.— Loss  of  body  weight  during  the  first  days 
of  life  occurs  so  constantly  in  full-term  infants  that  moderate 
losses  must  be  considered  physiological.  This  is  also  true  of 
premature  infants  although  in  most  instances  it  is  relatively  greater. 
Premature  infants  lose  relatively  more  and  regain  their  birth 
weight  more  slowly,  often  requiring  a  month  (De  Lee1)  and  also,  as  a 

i  See  page  30,  Ref.  4. 


42  PHYSIOLOGY 

general  rule,  the  nearer  the  prematures  are  to  full  term,  the  lower 
is  the  relative  loss  of  weight  as  expressed  in  percentages. 

The  average  loss  in  weight  in  the  premature  and  in  other  infants 
of  relatively  low  birth  weight  during  the  first  days  of  life  is  shown 
in  the  following  table  adapted  from  Reiche: 


Weight. 

Length. 

Average  decrease. 

800-1200  gm. 

32.0-40  cm. 

71  gm. 

1200-1500    " 

37.0-44    " 

97    " 

1500-2000    " 

40.0-48    " 

137    " 

2000-3500    " 

41.5-50    " 

177    " 

Gundobin's  figures  are  considerably  higher,  as  he  came  to  the 
conclusion  that  the  initial  loss  of  weight  in  infants  with  a  birth 
weight  under  2000  gm.  gm.  amounted  on  the  average  to  148  gm. 

The  artificially-fed  infants  lose  more  weight  than  the  breast  fed, 
but  no  differences  were  noticeable  between  those  infants  nursing 
at  the  mother's  breast  and  those  fed  by  a  wet-nurse  (Reiche) . 

In  children  of  muciparous  women  both  the  absolute  and  also  the 
relative  percentage  value  of  the  weight  loss  is  smaller  than  in  those 
of  primiparous,  which  is  undoubtedly  due  to  better  nursing  condi- 
tions, milk  appearing  sooner  in  multipara?  and  being  usually  more 
abundant. 

The  loss  of  weight  is  also  relatively  larger  the  less  the  birth 
weight  of  the  infant,  as  the  following  table  taken  from  Pies1  will 
show : 

Primiparse.  Multipara. 

Initial  weight.  Average  decrease.  Average  decrease. 

2500  gm.  240  gm.    =   11.2  percent  195  gm.  =8.2  percent 

2510-3000    "  235    "       =8.3        "  180    "  =6.2 

3010-3500    "  295    "=     9.0        "  265    "  =  8.1 

3510-4000    "  360    "      =9.7        "  325    "  =8.7 

4010-4500    "  245    "      =8.4         "  366    "  =8.3 


Average  275  gm.    =     9.3  per  cent  266  gm.    =   7.9  percent 

Initial  loss  in  weight  rests  upon  the  fact  that  the  new-born 
infant  gives  off  more  than  it  takes  in.  The  meconium  is  account- 
able for  a  considerable  part  of  the  loss.  This  averages  in  weight 
according  to  Camerer2  from  70  to  90  gm.;  according  to  Hirsch3 
from  150  to  200  gm.  In  addition  to  that,  the  urine  voided  before 
the  child  receives  much  fluid  must  be  considered,  though  this  is 
probably  small.  The  water  lost  through  the  lungs  and  skin,  the 
loss  of  the  stump  of  the  umbilical  cord,  and,  in  some  cases,  the 
vomiting  of  swallowed  liquor  amnii  during  the  first  twenty-four 

1  Ueber  die  Dauer,  die  Grosse  und  den  Verlauf  der  physiologischen  Abnahme  der 
Neugeborenen,  Monatschr.  f.  Kinderh.,  1911,  9,  51. 

2  Beitrag  zur  Physiologie  des  Sauglingsalters,  Ztschr.  f.  Biol,  1900,  39,  37. 

3  Die  physiologische  Gewichtsabnahme  der  Neugeborenen,  Berl.  klin.  Wchnschr., 
1910,  2. 


THE  GROWTH  OF  Till-:  PREMATURE  43 

hours,  are  all  factors  in  reducing  the  weight  of  the  new  horn.  Fur- 
thermore, it  has  been  shown  that  there  is  a  loss  of  the  body  tissues, 
of  the  fat,  glycogen  and  albumin,  as  evidenced  by  the  loose  and 
wrinkled  condition  of  the  infant's  skin,  and  lost  turgor  of  the  tissues 
in  general.  Landois1  found  that  the  loss  of  weight  in  infants  in 
whom  the  cord  was  tied  late  was  5.9  to  7. 1  per  cent  less  than  those 
in  whom  the  cord  was  tied  and  cut  early. 

Gundobin2  found  that  the  lowest  weight  was  usually  reached 
sometimes  between  the  fourth  and  sixth  (lays  in  the  full-term  infant 
and  that  the  birth  weight  was  regained  on  the  eleventh  to  the 
sixteenth  day.  Very  frequently,  however,  and  especially  in  weak- 
lings and  prematures,  the  birth  weight  was  not  regained  as  early 
as  the  sixteenth  day,  twenty  or  thirty  days  being  required  to 
make  up  the  initial  loss.  The  artificially-fed  regained  the  loss 
later  than  the  breast-fed  infants. 

Pfaundler,3  in  his  observations  on  1000  new-born  infants  came 
to  the  conclusion  that  the  physiological  weight  loss  occurred  in  42 
per  cent  by  the  fourth  day.  The  loss  in  the  infants  of  from  l.iOO  to 
4000  gm.  birth  weight  averaged  7.8  per  cent  of  the  latter,  and  was 
about  the  same  for  the  heavy  as  for  the  light,  although  it  was 
relatively  slightly  greater  in  the  former. 

Birth  weight.  Loss  in  weight. 

Over  4000  gm.  325  gm.  =   7.6  per  cent  of  the  birth  weight 

3500-4000    "  300    "  =   8.0       " 

3000-3500    "  250    "  =    7.7        "    .         "  " 

2500-3000    "  210    "  =7.6       "  " 

2000-2500    "  190    "  =8.4 

1500-2000    "  130    "  =7.4        "  "  " 


Average         7 . 8  per  cent 

Ramsey  and  Alley1  noted  in  300  cases  that  the  average  loss  of 
weight  continued  for  three  days  and  was  regained  by  the  tenth 
day  by  only  one-fourth  of  the  infants. 

Shick,5  believing  that  the  initial  loss  of  weight  was  avoidable, 
gave  each  infant  10  per  cent  of  its  body  weight  of  breast  milk 
the  first  twenty-four  hours,  increasing  the  amount  until  15  per 
cent  was  given  at  the  end  of  the  third  twenty-four  hours.  He 
employed  the  milk  of  mothers  having  infants  less  than  a  week  old 
and  was  able  to  prevent  the  initial  loss  in  all  of  his  twelve  cases. 

The  increase  in  weight  of  the  prematures  is  noted  in  the  table  on 
p.  44    in  a  group  of  the  author's  cases. 

1  Zur  Physiologie  der  Neugeborenen,  Monatsschr.  f.  Geb.  u.  Gyn.,  1905,  32,  194. 

2  Besondeiheiten  des  Kindesalters,  Berlin.  1912. 

3  Korpermass-Studien  an  Kindern,  Ztschr.  f.  Kinderh.,  .March  2S,  1916,  151-152. 

4  Observations  on  the  Nutrition  and  Growth  of  New-born  Infants;  an  Analysis  of 
300  ( ilinical  Charts,  Am.  Jour.  Dis.  Child.,  June,  1918,  15,  408. 

6  Zur  Frage  der  physiologischen  Korpergewichtsabnahme  der  Neugeborenen, 
Ztschr.  f.  Kinderh.,  1916,  13,  257. 


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Eighth 
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Tenth 
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THE  GROWTH  OF  THE  PREMATURE  15 

The  growth  of  the  premature  infant  has  been  well  shown  by  the 
tables  of  Camerer,1  who  figures  out  the  daily  average  increase  in 
ten  infants  who  had  a  birth  weight  ranging  from  1330  to  1!)7()  gm. 

Week  of  life  ...         0  2           4  8  12  16  20  24  28  32         30 

Weight  in  grams             1630  1830     2090  2636  3272  3906  4430  4068  5367  5717     6217 
Average  daily   gains 

in  grams 9         19  23  22  20  14  12  10  10 

Camerer  compared  the  increase  in  weight  in  breast-fed  and  bottle- 
fed  premature  infants  with  an  initial  weight  of  from  1590  to  1740 
gm. 

Doubled  weight.  Trebled  weight.         Quadrupled  weight. 

Breast  fed       .      .  10th  week  22d    week  33d    week 

Bottle  fed        .      .  11th     "  24th     "  40th     " 

Camerer's  further  figures  also  show  that  the  artificially-fed  full- 
term  infant  is  much  slower  in  its  weight  increase  than  the  breast-fed 
child. 

Average  Doubled  Trebled         Quadrupled 

birth  Number  of        weight,  weight,  weight, 

weight.  infants.  weeks.  weeks.  weeks. 

Breastfed       .      .  1680  8  12  24  52 

Artificially  fed      .  2420  18  18  44-48 

The  average  daily  increase  in  weight  of  the  premature  of  different 
periods  as  well  as  for  the  premature  child  is  shown  by  Friedenthal:1 

Fetal  months.  Average  daily  increase  in  weight. 

6th  to    7th 19.5  gm. 

7th  to    8th 29.3    " 

8th  to    9th 23.3    " 

9th  to  10th 13.3    " 

1st  month  of  mature  child 25.0    " 

The  growth  in  length  proceeds  slowly  from  month  to  month, 
diminishing  in  rate  (Friedenthal). 

Age.  Growth  in  length  per  month. 

6th  to  7th  fetal  month 6.0  cm. 

7th     "  "  5.0    " 

8th     "  "  4.5    " 

9th     "  "  4.0    " 

If  these  figures  of  Friedenthal's  are  plotted  into  a  curve  it  is  seen 
that  the  curve  of  the  body  weight  and  that  of  the  body  length  run 
parallel  up  to  the  seventh  or  eighth  month,  at  which  time  the 
length  curve  rises  less  abruptly  than  the  weight  curve. 

Pfaundler2  found  that  the  rate  of  growth  in  an  infant  born  three 
months  prematurely  became  the  same  as  that  of  a  maturely  born 
child  when  the  premature  had  reached  the  age  of  three  months. 

1  Med.  Wchnschr.,  1909,  No.  34.  2  See  p.  43,  Hef.  3. 


46  PHYSIOLOGY 

These  figures  apply,  of  course,  to  the  healthy  prematures  only  and 
not  to  those  debilitated  from  disease  or  by  unfavorable  environment 
or  food. 

Reiche's1  investigations  have  shown  that  the  growth  of  the 
prematures  follows  the  same  rules  of  growth  that  hold  good  for 
the  corresponding  months  after  impregnation.  In  healthy  prema- 
tures there  is  no  difference  between  the  intra-uterine  and  extra- 
uterine growth  in  the  same  months,  so  that  the  birth  in  itself  causes 
no  disturbance  of  growth  provided  that  the  infant  has  reached  a 
certain  stage  of  development,  compatible  with  the  exercise  of  certain 
indispensable  functions,  e.  g.,  respiration,  circulation  and  digestion. 
This  stage  of  development  is  seldom  reached  before  the  twenty- 
eighth  week  of  life,  when  the  infants  are  about  34  cm.  long  and 
weight  approximately  1  kg.  It  has,  therefore,  been  proposed  to 
designate  the  age  of  the  infant  from  the  time  of  conception  rather 
than  from  the  time  of  birth.  Serious  chronic  diseases  of  the  mother 
(especially  lues  and  tuberculosis)  exert  a  growth-inhibiting  influence 
upon  the  infant.  Their  progress  is  not  governed  by  the  same  laws 
that  hold  good  for  healthy  premature  infants. 

Reiche  has  also  studied  the  relation  between  the  growth  in 
weight  and  the  growth  in  length  and  has  introduced  the  term 
length-weight  coefficient,  by  which  is  understood  the  weight  of  a 
unit  of  length.  The  following  table  shows  the  birth-weight  coeffi- 
cient for  different  groups  of  prematurely  born  infants: 


Birth-weight. 

Length  of  body. 

Length 

-weight  coefficient. 

800-1200  gm. 

32.0-40  cm. 

28.0  gm. 

1200-1500    " 

37.0-44    " 

33.8    " 

1500-2000    " 

40.0-48    " 

43.2    " 

2000-2500    " 

41.5-50    " 

48.7    " 

Langstein2  formulated  the  following  law  from  the  observations 
of  Reiche  and  others:  Both  the  growth  in  mass  and  the  growth  in 
length  of  these  organisms  in  whom  the  transition  from  intra-uterine 
to  extra-uterine  life  had  to  occur  prematurely,  proceeds  according 
to  the  same  laws  that  correspond  to  the  period  of  time  after 
impregnation. 

The  majority  of  multiple  pregnancies  terminate  prematurely  and 
therefore  the  percentage  of  twins  among  the  prematurely  born  is 
considerably  higher  among  mature  children.  By  the  development 
of  more  than  one  child  in  the  mother's  womb  the  growth  may  be 
impaired,  and  this  consists,  as  a  rule,  in  impairment  of  growth  in 
mass,  only  in  exceptional  cases  in  impairment  of  growth  in  length. 

1  Ztschr.  f.  Khk.,  Dec,  1915. 

2  Ernahrung  und  Wachstum  Friihgeborener,  Bcrl.  klin.  Wclmschr.,  1915,  24. 


THE  GROWTH  OF  THE  PREMATURE  47 

But  even  in  these  prematurely  horn,  twins  have  a  tendency  in  their 
first  months  of  life  to  make  up  this  loss.  The  curves  of  growth  of 
twins  run,  as  long  as  no  intercurrent  diseases  interfere,  parallel  to 
each  other  and  also  to  the  curve  of  those  children  in  whom  a  larger 
difference  in  growth  was  present  at  birth.  The  proportions  of 
growth  between  the  circumference  of  the  thorax  and  the  circum- 
ference of  the  head  are  scarcely  influenced  by  multiple  pregnancy. 
In  individual  twins  even  these  curves  run  parallel  to  each  other. 

Weight  in  Relation  to  the  Body  Surface.— Ssytcheff1  gives  the 
following  table  comparing  the  surface  area  and  the  weight  in  the 
premature  and  in  older  children. 

Surface  area  per 
WT eight.  Surface  area,  kg.  of  weight. 

Age.  gm.  sq.  cm.  sq.  cm. 

Premature  four  days  old       .  1505  1266.4  841.4 

Newborn 2097  1476.0  704.0 

3  months  old        ....  3520  2279.0  647.0 

6           "            5138  2961.0  576.2 

1  year  old 9095  4800 .0  527 . 0 

Thus  it  is  seen  that  the  larger  the  volume  (weight)  of  the  infant 
the  smaller  the  surface  area  relative  to  that  weight. 

In  estimating  or  comparing  heat  loss  or  other  metabolic  processes 
relating  to  or  dependent  upon  surface  area,  it  is  evident  that  one 
should  have  an  exact  method  of  determining  that  area.  Meeh,2 
in  1879,  wTas  the  first  to  construct  a  formula  for  this  purpose,  the 
basis  for  which  was  the  observation  of  Molischott  that  the  volume 
of  bodies  of  similar  composition  and  form  varies  in  the  ratio  of  the 
cube  root  of  their  weight  and  their  surface  areas  in  the  ratio  of 
the  square  root  of  their  volume. 

Recent  investigations  have  given  us  two  reliable  formulae  for 
the  rapid  estimation  of  the  body  surface  of  the  infant,  those  of  Dubois 
and  DuBois3  and  of  Howland  and  Dana.4 

The  formula  of  Dubois  and  DuBois,  which  is  entirely  independent 
of  the  body  weight,  predicates  the  division  of  the  body  into  several 
regions,  the  various  measures  of  length  of  these  regions  being 
multiplied  by  the  sums  of  the  various  measurements  of  the  width, 
and  the  figure  thus  obtained  multiplied  by  the  constant  for  the 
given  region.  These  constants  have  been  worked  out  by  the 
investigators  and  represent  the  reciprocal  of  the  average  factor  for 
that  particular  combination  of  length  and  breadth  measurements 
which  showed  the  smallest  variations. 

1  Quoted  from  Gundobin,  Die  Besonderheiten  des  Kindesalters,  Allg.  mediz. 
Verlagsanstalt,  Berlin,  1912. 

2  Oberflachen  Messungen  des  menschlichen  Korpers,  Ztschr.  f.  Biol.,  1879,  vol.  15, 

3  Arch.  Int.  Med.,  1916,  863. 

*  A  Formula  for  the  Determination  of  the  Surface  Area  of  Infants,  Am.  Jour.  Di*. 
Child..  1913,  6,  33. 


48 


PHYSIOLOGY 


In  the  formula  proposed  by  Howland  and  Dana1  the  data  sup- 
plied by  Meeh  and  Lissauer2  were  used.     Meeh  had  included  3 


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Fig.  12. — Chart  showing  weight  and  surface  area  of  infants.     (Howland  and  Dana.) 


f  »  See  p.  47,  Ref.  4. 
2  See  p.  47,  Ref.  g. 


THE  GROWTH  OF  THE  PREMATURE 


49 


infants  among  his  observations  and  Lissauer  had  measured  the 
area  of  11,  making  14  in  all.  Howland  and  Dana  first  plotted  on 
a  chart  the  weight  and  surface  area  of  these  14  cases  and  then 
drew  a  curve  as  nearly  as  possible  to  all  these  points  so  that  the 
distance  from  any  point  would  be  as  small  as  possible. 

This  curve  (Fig.  12),  by  its  distance  from  the  axes    ox  and  oy, 
represents  an  average  of  the  observed  data,  so  that  when  drawn 


Fig.   13. — Dcrmatograph.     Apparatus  for  measuring  body  surface.     (Pfaundler.) 

to  the  proper  scale,  the  point  on  the  curve  representing  any  known 
weight  of  the  child  may  be  marked  on  the  chart  and  the  surface 
area  read  off  directly.  Thus,  if  one  has  an  infant  weighing  7000 
gm.  and  it  is  desired  to  know  its  surface  area,  one  finds  where  the 
7000  gm.  line  intersects  the  curve.  Carrying  this  point  horizontally 
to  the  left,  it  is  seen  to  intersect  the  oy  axis  at  a  point  corresponding 
to  4100  sq.  cm. 
This  formula,  u  equals  mx  plus  b,  is  the  algebraic  representation 
4 


50  PHYSIOLOGY 

of  this  form  of  curve,  and  in  it  x  and  y  represent  the  abscissas  and 
ordinates  of  the  curve,  b  represents  the  distance  along  the  y  axis,  and 
m  represents  the  tangent  of  the  angle  that  the  curve  marked  with 
the  x  axis. 

In  this  formula: 

y  =  surface  area  of  child  in  square  centimeters. 

x  =  weight  of  child  in  grams, 

m  =  0.483. 

b  =  750. 

The  factor  b  was  read  directly  from  the  chart  and  m  was  obtained 
by  dividing  5560  minus  730  by  10,000.  Having  these  last  three 
quantities,  it  becomes  possible  to  obtain  the  y  or  surface  area  by 
simple  computation— the  weight  times  0.483  plus  730. 

Pfaundler,1  in  1916,  reviewed  the  previous  methods  of  measuring 
body  surface  and  elaborated  a  new  method  based  on  the  principle 
that  the  body  surfaces  are  usually  in  the  form  of  a  cylinder  or 
obtuse  cone.  The  body  was  divided  into  sixteen  regions  by  use 
of  an  instrument— dermatograph,  and  the  areas  added  to  give  the 
total  surface.     This  instrument  is  illustrated  in  Fig.  13. 


CHARACTERISTICS  OF  VARIOUS  ORGANS. 

Respiratory  Tract.— One  of  the  most  marked  features  of  the 
premature  and  of  the  congenitally  weak  are  the  poor  respiratory 
efforts,  indeed,  Billiard2  has  defined  congenital  weakness  as  "the 
incomplete  establishment  of  respiration."  The  premature  in 
response  to  the  need  of  air,  inspires  at  birth,  but  its  muscular  power 
is  weak  and  its  efforts  are  insufficient  to  raise  the  thoracic  wall 
and  thus  dilate  the  pulmonic  cavity.  As  a  result,  though  the 
large  bronchi  are  rilled  with  air,  many  of  the  small  bronchioles 
are  not  dilated  and  a  large  portion  of  the  lung  continues  to  remain 
in  a  fetal  stage,  and  may  require  several  weeks  for  its  complete 
expansion.  The  reason  for  this  poor  functioning  of  the  organs  of 
respiration  lies  in  the  lack  of  development  of  the  respiratory  centers 
in  the  medulla. 

Most  observers  state  that  the  chest  wall  of  the  premature  infant 
is  more  or  less  immobile,  moving  but  slightly  with  each  respiration, 
but  it  has  been  our  experience  that  quite  constant  evidence  of 
prematurity  is  shown  in  the  flexibility  of  the  thorax  and  its  tendency 
to  retraction  with  each  inspiration,  the  seeming  immobility  being 
the  result  of  the  poor  effort  on  the  part  of  the  muscles  of  respiration, 

1  Korpermass-Studion  an  Kindern,  Ztschr.  f.  Kinderh.,  March  28,  1916,  Bd.  14, 
1-148. 

2  Traite  des  maladies  des  enfants  nouveau  nes,  1833,  73. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  51 

due  to  their  weakness.  The  chest  walls  can  expand  but  the  mus<  u- 
lar  power  is  insufficient  to  make  them  do  so.  This  muscular  inertia, 
which  is  so  well  evidenced  in  these  infants,  is  therefore  partly  the 
result  of  poorly  developed  muscles  and  partly  the  result  of  deficient 
innervation  due  to  a  similar  lack  of  development  of  the  cerebral 
centers. 

Accompanying  the  deficient  oxygenation  of  the  blood  are  attacks 
of  cyanosis,  during  which  respiration  ceases  entirely.  This  apneic 
interval  lasts  for  one  or  two  minutes  and  then  breathing  is  resumed. 
These  attacks  are  not  at  all  infrequent  during  the  first  fortnight 
and  often  appear  without  warning.  In  those  cases  in  which  recov- 
ery occurs  the  attacks  become  less  frequent  and  less  severe,  but 
when  unrelieved  they  are  of  grave  significance  and  not  uncommonly 
result  fatally. 

Clinically  the  weakened  respirations  are  manifested  by  the 
monotonous,  feeble,  whining  cry  and  grunting  expirations  with 
comparative  immobility  of  the  thorax,  and  the  superficial  and  often 
irregular  character  of  the  respirations,  which  become  abdominal  in 
type.  While  a  child  born  at  the  sixth  month  may  breathe  for 
hours  or  days,  previous  to  that  time  respiration  is  not  fully  estab- 
lished. Even  though  respiratory  exchange  does  not  occur,  the 
heart  may  be  found  beating  several  hours  after  birth . 

The  frequency  of  respiration  in  the  sleeping  premature  immedi- 
ately after  birth  is  frequently  as  high  as  40  to  50  per  minute.  When 
awake  the  rate  is  about  50  or  more  unless  the  infant  is  crying,  when 
it  is  much  less  than  in  ordinary  breathing.  The  type  of  respiration 
in  the  premature  is  essentially  diaphragmatic,  superficial  and 
irregular,  showing  interruptions  particularly  during  crying  when 
these  pauses  may  be  quite  long.  The  soft  and  yielding  character 
of  the  thoracic  wall  in  the  premature  permits  of  slight  degrees  of 
retraction  of  the  lower  intercostal  spaces  during  the  deeper  inspi- 
rations. 

The  physical  findings  over  the  lungs  of  premature  infants  are 
uncertain.  On  inspection  and  palpation  the  thorax  shows  deficient 
mobility,  on  percussion  the  sounds  over  the  bases  are  lower  than 
over  the  balance  of  the  chest,  and  on  auscultation  the  vesicular 
murmur  is  hardly  perceptible.  At  autopsy  these  signs  are  con- 
firmed and  the  lower  parts  of  the  lungs  particularly  are  seen  to  be 
atelectatic,  at  times  the  major  portion  of  the  organ  being  involved, 
making  gaseous  interchange  very  difficult. 

The  complete  establishment  of  respiration  may  be  prevented  not 
only  by  the  weakness  of  the  respiratory  movements  but  by  the 
aspiration  of  liquor  amnii  or  mucus  during  the  last  moments  of 
delivery,  which  mechanically  prevents  the  entrance  of  air  into 
the  pulmonary  alveoli.     (See  Atelectasis.) 


52  PHYSIOLOGY 

Parrot,1  Billiard2  and  others  have  noted  a  condition  which  is 
spoken  of  as  life  without  respiration,  of  which  the  characteristic 
manifestations  are  the  absence  of  thoracic  movements,  the  presence 
of  a  pulse  and  of  movements  of  the  extremities,  and  the  absence 
of  asphyxia  immediately  after  birth.  The  persistence  of  the 
ductus  arteriosus  renders  this  condition  supportable,  as  it  allows  the 
blood  to  pass  directly  into  the  aortic  current  without  passing 
through  the  lungs.  Such  infants  remain  in  their  intra-uterine 
state  of  apnea  until  the  respiratory  centers  become  sufficiently 
irritated  by  the  increasing  venous  blood  to  evoke  respiratory 
action.  This  life  without  respiration  should  not  be  confounded 
with  the  apparent  death  of  children  born  at  or  before  term.  Appa- 
rent death  has  two  forms:  The  syncopal  form,  which  is  characterized 
by  pallor  of  the  skin  and  absence  of  pulse,  and  the  asphyxiated 
form,  distinguished  by  cyanosis  of  the  skin  and  the  presence  of  a 
pulse  beat.     (See  Apparent  Death.) 

The  nasal  passages  of  the  new-born  prematures  are  particularly 
narrow,  favoring  the  easy  occurrence  of  stenosis  in  inflammatory 
conditions  involving  the  nasal  mucosa. 

Interference  with  respiration  also  results  from  the  aspiration  of 
food  or  vomited  matter  into  the  larynx  or  trachea,  the  lack  of 
development  of  the  pharyngeal  and  laryngeal  reflexes  being  respon- 
sible for  the  not  infrequent  occurrence  of  this  accident.  Attempts 
at  drinking  sometimes  result  in  mechanical  hindrance  of  obstruction 
to  inspiration  during  the  act  of  swallowing.  Aspiration  of  food  is 
often  followed  by  a  pulmonary  infection  and  thus  atelactasis  of  the 
lung  may  be  said  to  predispose  to  a  pneumonia  which  not  infre- 
quently leads  to  death.     (See  Infections  of  the  Lungs.) 

Jaschke3  considers  the  deficient  function  of  the  respiratory 
apparatus  as  being  due  to  the  fact  that  the  irritability  of  the  respi- 
ratory center  is  so  low  that  a  large  accumulation  of  carbonic  acid 
in  the  blood  is  necessary  to  make  it  act.  With  the  sinking  of  the 
carbonic-acid  tension  with  stronger  respirations,  the  depth  of 
respiration  decreases  again,  because  of  lowered  stimulation  of  the 
respiratory  center  and  finally  a  point  is  reached  in  which  the  blood 
is  arterialized,  when  the  respiratory  center  no  longer  responds. 
A  pause  in  respiration  sets  in  and  lasts  until  excess  of  carbonic  acid 
stimulates  new  respiratory  movements. 

A  further  point  is  brought  out  by  Jaschke.  There  appears  to 
be  a  disturbance  of  the  gaseous  interchange,  which  is  probably 
explained  by  the  peculiarity  of  the  blood  serum  of  debilitated 
premature  infants.  This  was  first  noted  by  Pfaundler.4  The 
blood  serum  shows  a  diminution  of  the  OH  ions,  and  a  correspond- 

i  L'athrepsie,  Paris,  1877.  2  See  p.  50,  Ref.  2. 

3  See  p.  18,  Ref.  1.  4  Quoted  from  Jaschke. 


CHARACTERISTICS  OF  V ARK) IS  0 ROANS 


53 


ingly  greater  concentration  of  the  II  ions,  which  condition  makes 
the  draining  of  carbonic  acid  from  the  tissues  more  difficult. 
Jaschke  believes  that  this  agrees  with  Finkelstein's1  theory  that 
the  attacks  of  cyanosis  are  to  be  regarded  as  an  expression  of  a 
chronic  carbonic-acid  intoxication. 


Fig.    14. — Roentgenogram  showing  position  of  stomach  in  a  sixteen  weeks'  fetus. 


The  Digestive  Tract.  — I.  Anatomy. — The  muscles  of  the  buccal 
region,  of  the  tongue  and  of  the  soft  palate  are  weak. 

The  stomach  of  the  premature  infant  before  its  first  feeding,  as 
seen  in  autopsy,  is  in  an  almost  vertical  position  and  tubular  in 
its  form.  In  the  premature  infant  which  has  been  fed  the  fundus 
is  fairly  well  developed  and  causes  the  stomach  to  assume  a  more 
oblique  position.  This  is  corroborated  by  a  roentgen-ray  examina- 
tion (Figs.  14  and  15). 

1  Quoted  from  Jaschke. 


54 


PHYSIOLOGY 


A.  F.  Hess1  was  able  to  demonstrate  that  the  gastric  canal  of  the 
infant  is  more  nearly  vertical  than  horizontal,  and  that  therefore 
from  a  functional  standpoint  the  infant's  food  traverses  the  gastric 
canal  in  a  vertical  rather  than  a  horizontal  path,  even  though  the 
stomach  lies  more  or  less  horizontally.  This  fact  is  even  more 
true  of  the  physiological  path  of  the  food  in  the  premature  (Fig.  1(>). 


Fig.    15. — Roentgenogram    showing  position  of  stomach  in  a    still-born,  full-term 

infant. 

The  cardiac  end  of  the  stomach,  is  found  well  to  the  left  and 
usually  about  the  level  of  the  tenth  dorsal  vertebra.  The  cardiac 
sphincter  is  usually  poorly  developed  (Fig.  17).  This  in  part 
accounts  for  the  ease  with  which  the  premature  infant  regurgitates 
its  food.     The  pylorus  lies  somewhat  higher  than  that  of  the  full- 


1  Am.  Jour.  Dis.  Child.,  1912,  3,  133. 


CHARACTERISTICS  OF   VARIOUS  ORCAXS 


.).) 


term  new-born,  in  whom  it  is  found  about  midway  between  the 
ensiform  cartilage  and  the  umbilicus.  Before  feeding  it  is  almost 
always  found  to  the  left  of  the  median  line.  The  pyloric  muscula- 
ture is  usually  quite  well  developed,  even  in  the  new-born  premature 
(Figs.  IS,  19  and  20). 


' 

^  ■ 

.... 

* 

Fig.    16. — Roentgenogram  of  stomach  immediately  after  feeding  showing  oblique 
position  and  early  passage  of  food  through  the  pylorus. 

The  musculature  of  the  stomach  at  autopsy  in  the  new-born  pre- 
mature is  in  a  state  of  contraction,  giving  the  stomach  a  tubular 
appearance.  In  the  living,  however,  this  tubular  appearance 
quickly  disappears  with  the  administration  of  food,  the  fundus 
enlarging  much  more  rapidly  than  the  balance  of  the  stomach  in 
order  to  meet  the  physiological*  demands. 

Gastric  Ca pacify.— Although  many  authors  have  measured  the 
full-term  infant's  stomach  as  to  its  capacity,  both  at  autopsy  and 
in  the  living,  their  figures  vary  considerably. 

Mosenthal,1  after  a  careful  study  of  full-term  infants  measured 


>  Arch.  Pediat.,  1009,  26,  761. 


Fig.  17.— Section  through  the  esophagus  near  its  junction  with  the  stomach  of  a 
fetus,  aged  thirty-two  weeks.  Normal  size  and  enlarged  10  diameters.  Section 
taken  from  stomach  shown  in  Fig.  24. 


Fig.  18. — Transverse  section  through  the  middle  of  the  fundus  of  the  stomach  of  a 
fetus  of  twenty-two  weeks.  The  glands  have  shallow  crypts,  in  this  case  filled  with 
coagulated  mucin.  The  glandular  portion  of  the  section  is  not  so  thick  as  in  the 
adult.  There  are  a  few  parietal  cells  at  the  base  of  the  fundus  glands.  Normal  size 
and  enlarged  10  diameters. 


Fig.  19. — Transverse  section  through  the  pyloric  end  of  the  stomach  of  a  fetus  of 
twenty-four  weeks.  The  long  pyloric  glands  have  deep  crypts  between  them,  repre- 
senting a  close  approach  to  the  adult  type.  The  absence  of  Brunner's  glands  removes 
it  from  the  immediate  vicinity  of  the  pyloric  sphincter.  Normal  size  and  enlarged 
10  diameters.     Taken  from  stomach  in  Fig.  23. 


5^3 

v^s 

«Hff 

mSsfip '  }M 

KEM 

jBttQSI^B  1 

&? 

WpHQ 

iB^m''   it 

Fig.  20. — Transverse  section  through  the  pyloric  end  of  the  stomach  of  a  fetus 
of  twenty-eight  weeks.  Normal  size  and  enlarged  10  diameters,  taken  from  stomach 
in  Fig.  23. 


5§  physiology 

during  life  and  post  mortem,  states  that  the  physiological  capacity 
of  the  stomach  exceeds  the  anatomical  gastric  capacity  during  life 
because  of  the  rapid  passage  through  the  pylorus  of  the  individual 
feedings  during  the  act  of  nursing.  This  fact  is  corroborated  by 
the  roentgen  ray  (Fig.  16)  in  several  of  our  cases.  Therefore,  the 
gastric  capacity,  as  measured  post  mortem  by  filling  the  stomach 
with  water  under  pressure  of  15  cm.  of  water  with  the  pyloric  end 
of  the  stomach  ligated,  must  also  fall  short  of  giving  the  exact 
functional  capacity. 

Pfaundler's1  figures  for  the  stomach  capacity  during  the  first 
three  months  of  life  for  the  full-term  infant  are  90,100  and  110  cc. 

Holt2  gives  the  following  averages  for  stomach  capacity  in  a 
series  of  studies  made  on  infants  dying  during  the  first  four  weeks 
of  life  and  examined  post  mortem. 

Age.  No.  of  cases.  Capacity. 

Birth  5  36     cc. 

Two  weeks  7  45     " 

Four  weeks  4  60     " 

Notwithstanding  the  fact  that  distention  of  the  stomach  accord- 
ing to  the  method  of  Pfaundler  at  autopsy  is  far  from  an  ideal 
method  of  estimating  the  physiological  capacity  of  the  stomach, 
the  author  has  undertaken  to  measure  the  stomach  capacity  for 
the  various  fetal  ages  after  the  sixth  month  by  this  method,  and 
to  illustrate  the  same  graphically  by  photographs  which  represent 
the  actual  size  of  these  stomachs  at  various  fetal  ages.  This  has 
been  done  more  especially '  to  illustrate  the  dangers  of  individual 
overfeedings  which  are  so  disastrous  to  the  life  of  the  premature. 

Figs.  21  to  26  are  photographs  taken  with  specimens  immersed 
in  oil  and  represent  the  exact  size  of  the  stomach  under  15  cm. 
of  water  pressure  at  different  ages. 

The  stomach  of  the  premature  infant  on  a  diet  of  breast  milk 
is  usually  found  empty  at  the  end  of  one  and  one-half  to  two  hours. 
That  of  the  artificially  fed  requires  a  considerably  longer  period  of 
time,  depending  upon  the  nature  of  the  food  administered,  even 
in  the  case  of  feeding  with  predigested  milk. 

2.  Physiology.— The  digestive  functions  of  the  healthy  premature 
infant  are  proportionate  to  the  age  at  the  time  of  birth.  At  the 
sixth  or  seventh  month  most  of  the  functions  and  secretions  are 
rudimentary  and  insufficient,  while  in  the  older  infants  the  lessening 
of  digestive  ability  is  not  so  great. 

The  sucking  ability  in  the  prematures  and  weaklings  is  feeble 
as  a  result  of  the  lack  of  muscular  strength  necessary  to  operate 

1  Magenkapazitat  in  Kindersalter,  Wien.  klin.  Wchnschr,    1897,  44. 

2  Diseases  of  Infancy  and  Childhood,  New  York  and  London,  1911,  p.  309. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  59 


Fig.  21. — Stomach  estimated  fetal  age  twenty-four  weeks  capacity,  5  cc 


Fig.  22. — Stomach  estimated  fetal  age  twenty-six  weeks  capacity,  8  cc. 


Fig.  23. — Stomach  estimated  fetal  age  twenty-eight  weeks,  capacity  10  cc. 


60  PHYSIOLOGY 

the  suction,  the  muscles  of  the  buccal  region,  of  the  tongue  and 
of  the  soft  palate  being  weak.  Accompanying  this  muscular 
asthenia  is  an  inactivity  of  the  salivary  glands,  as  a  result  of  which 
the  mouth  is  dry.  The  lack  of  sucking  movements  tends  also  to 
retard  the  development  of  these  glands. 


Fig.  24. — Stomach  estimated  fetal  age  thirty-two  weeks,  capacity  18  cc. 

The  strength  to  swallow  is  also  diminished  in  the  premature. 
In  the  weakest  a  few  drops  of  milk  placed  in  the  mouth  remain 


Fig.  25. — Stomach  estimated  fetal  age  thirty-six  weeks,  capacity  25  cc. 

there;    in  the  stronger,  though  at  first  they  nurse,  they  soon  tire 
and  their  efforts  to  swallow  cease. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  61 

"Hunger  contractions"  were  studied  by  Taylor1  in  5  premature 
and  40  full-term  new-born  infants.  A  comparison  of  the  con- 
tractions in  the  new  born  with  several  older  children  showed  that 
the  hunger  contractions  in  the  former  were  greater  than  in  the 
latter.  Reflex  inhibition  from  the  presence  of  food  in  the  stomach 
was  present  in  infants  of  all  ages.  The  time  of  appearance  of 
hunger  after  feeding  in  healthy  infants  gaining  in  weight  and 
receiving  a  sufficient  amount  of  food  was:  For  premature  infants 
under  one  month,  one  hour  and  forty  minutes;  in  full-term  infants 
under  two  weeks,  two  hours  and  fifty  minutes;  in  infants  from 
two  weeks  to  four  months,  three  hours  and  forty  minutes. 


Fig.  26. — Stomach  estimated  fetal  age  forty  weeks,  capacity  45  cc. 

The  ferments  of  the  gastro-intestinal  canal  are  most  conveniently 
discussed  from  the  standpoint  of  action.  The  first  group  arc 
those  that  aid  in  the  splitting  up  of  protein  substances. 

Pepsin  is  present  in  the  gastric  mucosa  as  early  as  the  fourth 
fetal  month,  though  not  in  such  quantities  as  in  the  older  children. 
It  increases  in  amounts  up  to  about  the  third  month  of  life  and 
then  remains  at  about  that  level.  Hydrochloric  acid  and  rennin 
are  also  present  in  fetal  life.  Hess2  was  able  to  demonstrate  free 
hydrochloric  acid  in  54  out  of  55  cases  immediately  after  birth. 

1  Hunger  in  the  Infant,  Am.  Jour.  Dis.  Child.,  October,  1917, 14,  233. 

2  Gastric  Secretion  of  Infants  at  Birth,  Am.  Jour.  Dis.  Child.,  1913,  6,  264. 


62  PHYSIOLOGY 

Lipase  was  found  to  be  present  in  small  quantities  by  Ibrahim1 
in  a  fetus  of  800  gm.  and  plainly  present  in  those  from  1100  gm. 
upward.     Sedgwick2  had  previously  demonstrated  it  in  1905. 

Trypsin  is  present  in  the  pancreatic  extract  of  the  new  born. 
Ibrahim  found  trypsinogen  as  early  as  the  sixth  fetal  month  and 
enterokinase  was  also  found  by  him  in  an  extract  of  intestinal 
mucosa  from  premature  infants.  The  lower  third  of  the  small 
intestine  is  most  active  in  the  production  of  enterokinase. 

Secretin,  the  ferment  which  activates  the  pancreas,  was  found 
in  the  small  intestine  of  the  full -term  hew  born  by  Ibrahim  and 
Gross,3  but  its  activity  was  slight.  In  the  premature  it  is  probably 
even  more  deficient. 

Erepsin  splits  albumoses  and  peptones  and  originates  from  the 
mucosa  of  the  small  intestine.  It  has  been  demonstrated  in  the 
premature  by  Langstein,4  Jseggis,5  Cohnheim6  and  others. 

The  next  group  consists  of  the  carbohydrate  ferments,  of  which 
the  milk-sugar  ferment  lactase  is  found  in  the  intestinal  contents, 
the  stools  and  the  intestinal  mucosa.  It  is  frequently  absent  from 
the  intestinal  tract  of  the  premature,  as  it  makes  its  appearance 
rather  late  in  fetal  life.  Nothmann7  was  able  to  demonstrate  it 
in  the  stools  of  the  mature  new  born  in  only  a  few  cases.  The 
presence  of  relatively  large  amounts  of  milk  sugar  in  the  infant's 
food  probably  increases  the  amount  and  activity  of  the  lactase. 
The  deficiency  of  lactase  at  birth  is  indicated  further  by  the  finding 
of  lactose  in  the  urine  of  new-born  infants  (Nothmann).  This 
would  seem  to  point  to  a  lack  of  milk-sugar  fermentation  (von 
Reuss) . 

The  cane-sugar  splitting  ferments,  invertin  and  saccharose,  are 
present  at  an  early  date  in  embryonal  life,  although  there  is  no 
use  for  them  in  those  fed  on  human  milk  or  where  lactose  is  used 
artificially,  for  a  long  period  of  time.  They  are  found  in  the 
intestinal  walls  and  in  the  meconium. 

Maltose  is  present,  according  to  Ibrahim,8  in  all  parts  of  the 
small  intestines  and  in  the  intestinal  contents  of  prematures. 
Diastase,  the  amylolytic  ferment,  is  present  in  the  salivary  glands 
and  in  the  pancreas  of  the  new  born.  Ptyalin  is  found  in  the 
parotid  and  in  the  submaxillary  secretions,  although  it  is  not 
required  until  the  beginning  of  the  starch  feeding.     Ibrahim  believes 

1  Verhandl.  d.  deutsch.,  Gesellsch.  f.  Kinderh.,  Koln,  1908,  p.  36. 

2  Arch.  Pediat.,  1906,  23,  414. 

s  Jahrb.  f.  Kinderh.,  1908,  68,  232. 
4  Jahrb.  f.  Kinderh.,  1908,  68,  9. 
6  Zentralb.  f.  Gyn.,  1907,  1060. 

6  Ztschr.  f.  Physiol.  Chem.,  1903,  37,  467. 

7  Monatsschr.  f.  Kinderh.,   1909,  8,  377. 

8  Ztschr.  f.  Physiol.  Chem.,  1910,  64,  95. 


CHARACTERISTICS  OF   VARIOUS  ORGANS  63 

that  the  pancreatic  function  of  the  new  born  and  espei  ially  of  the 

premature  new  horn  is  somewhat  below  that  of  the  older  infant, 
and,  therefore,  the  instructions  of  the  older  clinicians  not  to  feed 
these  infants  mixtures  containing  much  starch  were  correct  from 
a  physiological  point  of  view  (von  Reussj. 

The  third  and  last  group  of  ferments  are  those  which  act  upon 
the  fats.  Steapsin  was  found  in  the  pancreatic  secretion  by  Zweifel,1 
and  Ibrahim2  showed  that  it  was  also  present  in  the  premature. 
The  meconium  contains  this  ferment.  Lipase  is  very  active  in 
the  gastric  mucosa  of  prematures. 

In  general  the  premature  may  be  said  to  possess  nearly  all  the 
ferments  necessary  for  the  breaking-down  of  its  food.  Some  of 
them,  such  as  diastase  and  ptyalin,  which  are  not  present  during 
fetal  life  or  only  in  the  most  insignificant  quantities,  are  called 
forth  even  in  the  premature,  by  the  administration  of  food,  and 
though  they  may  be  deficient  both  in  amount  and  in  activity  at 
this  time,  the  continued  stimulation  offered  by  food  soon  results 
in  a  material  increase  in  both  qualities,  at  least  in  the  case  of  pre- 
matures who  possess  a  sufficient  degree  of  vitality.  All  necessary 
ferments  being  present,  it  is  of  little  advantage  to  feed  the  prema- 
ture infant  predigested  human  milk. 

Ferment  therapy  also  is  of  little  value  in  premature  infants  as  is 
also  true  in  older  children.  If  the  required  ferments  are  present 
they  will  increase  with  the  giving -of  food.  It  is  not  the  absence 
of  ferments  that  is  responsible  for  the  peculiarities  of  action  of  the 
digestion  of  the  prematures,  but  rather  the  way  the  food  is  broken 
down  and  absorbed;  and  a  clear  realization  of  these  differences  is 
necessary  to  an  understanding  of  the  peculiarities  of  the  digestion 
of  the  new  born,  both  premature  and  at  term. 

The  normal  gastric  mucosa  provides  only  for  the  absorption  of 
salts  and  carbohydrates. 

Ganghofer  and  Langer3  found  that  up  to  the  fourth  day  of  life 
the  intestinal  tract  is  permeable  to  foreign  proteins  and  the  import- 
ance of  this  is  great.  The  permeation  of  these  through  the  intesti- 
nal wall  results  in  the  formation  of  antibodies  in  the  tissues,  and 
the  danger  of  sensitization  of  the  organism  to  that  particular 
protein.  Herein  lies  one  of  our  most  important  indications  for 
feeding  with  human  milk. 

The  intestinal  canal  is  more  frail  than  in  the  full-term  infants 
and  the  intestinal  musculature  is  weak  and  easily  distended  and 
often  times  unable  to  expel  the  contained  meconium. 

The  meconium-  begins  to  he  formed  at  the  fourth  fetal  month. 

1  Untersuchungen  iiber  das  Verdauungsapparat  der  Neugeborenen,  Berlin,  1874. 

2  See  p.  62,  Ref.  1. 

3  Miinchen.  med.  Wchnschr.,  1904,  1497. 


64 


PHYSIOLOGY 


It  is  made  up  of  the  secretions  of  the  gastro-intestinal  tract,  vernix 
caseosa,  threads  of  mucus,  desquamated  epithelium,  biliary  acids 
and  salts,  cholesterol,  fat  droplets,  fatty-acid  crystals  and  liquor 
amnii  which  has  been  swallowed.  That  which  is  passed  on  the 
first  day  is  dark  green,  thick,  sticky,  homogeneous  and  odorless. 
Its  excretion  lasts  from  twenty-four  to  ninety-six  hours.  During 
the  first  few  hours  it  is  free  from  bacteria  and  even  later  the  number 
of  organisms  present  is  small.  The  characteristic  yellow  color  of 
the  breast  milk  stool  is  scarcely  established  before  the  fifth  and 
sixth  day  and  then  only  when  the  milk  taken  is  rich.  The  sour  odor 
of  the  breast-milk  stool  may  also  be  recognized  at  this  time. 

Hymanson  and  Kahn,1  investigating  the  properties  of  meconium 
found  that  there  were  traces  of  ammonia  and  amylase,  but  no 
uric  acid,  trypsin,  erepsin,  lactase  or  lipase.  Their  analysis  of  the 
inorganic  constituents  is  given  in  the  table  which  follows: 


1. 

2. 

3. 

4. 

5. 

Parts  per  thousand: 

732.3 

801.7 

784.5 

697.7 

718.6 

267.7 

198.3 

215.5 

302.3 

281.4 

Organic  matter 

245.2 

180.1 

197.7 

280.5 

257.9 

Ash 

22.5 

18.2 

17.8 

21.8 

23.5 

Ash  percentage  of: 

Total  meconium 

2.25 

1.82 

1.78 

2.18 

2.35 

•  8.3 

9.1 

8.2 

7.2 

8.3 

Analysis  of  meconium  ash  (per  cent) : 

Fe203 

3.17 

1.17 

2.24 

0.92 

1.44 

CaO 

18.24 

17.55 

21.18 

16.34 

MgO 

4.21 

8.05 

6.17 

6.18 

4.75 

P2O5 

12.62 

8.62 

11.70 

SOs 

23.14 

25.63 

18.47 

28.30 

24.32 

CI 

5.86 

7.12 

6.89 

5.34 

24.19 

33 .  72 

3.  Bacteriology  of  the  Gastro-intestinal  Tract.— The  gastro- 
intestinal tract  of  a  healthy  premature  is  sterile  at  birth  and 
remains  so  for  a  short  time  afterward,  the  meconium  remaining 
sterile  for  about  twelve  hours.  This  is  followed  by  invasion  of 
bacteria,  most  probably  with  the  first  feeding,  and  during  the 
next  two  days  the  gastro-intestinal  flora  is  very  variable,  depending 
chiefly  on  the  surroundings  of  the  infants.  After  the  third  day, 
however,  a  typical  intestinal  flora  develops,  the  type  depending 
chiefly  upon  the  diet  of  the  infant. 

In  an  infant  fed  with  human  milk  saccharolytic  bacteria  pre- 
dominate, the  chief  one  being  Bacillus  bifidus,  which  is  especially 

1  Study  of  the  Intestinal  Contents  of  Newly  Born  Infants,  Am.  Jour.  Dis.  Child., 
February,  1919,  17,  112. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  65 

numerous  in  the  large  intestine  up  to  the  sigmoid  flexure.  This 
portion  of  intestine  also  contains  the  largest  number  of  bacteria. 
Bacillus  coli  is  also  present,  especially  in  the  region  of  the  ileocecal 
valve  and  cecum,  but  still  Bacillus  bifidus  predominates.  The 
flora  of  an  infant  on  human  milk  are  much  more  homogeneous  than 
that  of  an  infant  artificially  fed. 

In  artificially-fed  infants  there  is  a  relative  increase  of  Bacillus 
coli  and  of  proteolytic  bacteria  and  a  diminution  of  Bacillus  bifidus. 
However,  the  flora  of  artificially-fed  infants  arc  much  more  variable 
and  depend  chiefly  on  the  chemical  composition  of  the  food. 

Human  milk  low  in  protein  and  high  in  sugar  leads  to  the  flora 
of  fermentation,  while  cows'  milk  which  is  high  in  protein  and  low 
in  sugar  leads  to  flora  of  putrefaction. 

Carbohydrates  favor  the  development  of  fermentative  organisms, 
lactose  favoring  especially  Bacillus  bifidus  and  maltose  and  dextrin 
compounds  favoring  Bacillus  acidophilus. 

Proteins  favor  the  development  of  organisms  of  putrefaction, 
especially  when  given  in  excess. 

Fat  seems  to  have  no  distinctive  action  on  the  intestinal  flora. 

Metabolism  of  Premature  Infants. — The  following  facts  are 
quoted  from  Jaschke,1  who  states  that  there  is  not  sufficient  material 
on  hand  at  the  present  time  for  comparing  the  metabolism  of 
prematures  both  healthy  and  debilitated  with  the  metabolism  of 
mature  normal  infants. 

"The  expenditure  of  energy  as  related  to  the  unit  of  body  surface 
is  in  the  premature  much  greater  than  in  the  mature  new  born 
(Camerer),  when  the  age  is  calculated  from  birth;  on  the  other 
hand,  however,  they  are  almost  the  same,  if  age  is  calculated  from 
the  time  of  conception  (Pfaundler)  which  very  well  agrees  with  the 
curve  of  the  potential  of  life.  The  nitrogen  under  balance  in  the 
premature  lasts  longer  than  in  the  mature  new  born,  which  is 
probably  dependent  in  the  first  place  upon  the  small  food  intake. 
There  are  not  sufficient  experiments  on  the  gaseous  exchange  and 
on  the  insensible  perspiration  to  enable  one  to  draw  conclusions 
that  would  be  of  general  value.  There  is  nothing  known  of  mineral 
metabolism." 

Nervous  System.— The  lack  of  development  of  the  cerebrospinal 
nervous  system  is  greater  than  that  of  the  sympathetic  system.  It 
is  most  markedly  evidenced  by  the  muscular  inertia  shown  by  the 
infant.  Many  of  them  lie  in  a  state  of  stupor  or  somnolence  from 
which  they  must  be  aroused  to  be  fed.  Others  can  be  aroused  by 
external  stimulation  which  calls  forth  only  a  weak  cry  and  slight 
movements  of  the  body.     These  movements  are  slower  than  those 

i  Sec  p.  18,  Ref.  1. 


66  PHYSIOLOGY 

of  the  full-term  infant  and  the  child  tends  to  relapse  into  a  deep 
sleep  as  soon  as  the  stimulus  is  removed.  Also  depending  to  some 
extent  upon  the  incomplete  development  of  the  nervous  centers 
are  the  weak  respiratory  functions  and  the  feeble  efforts  at  sucking. 
At  this  time  the  development  of  the  brain  is  still  going  on  and  the 
separation  of  the  white  and  gray  matter  is  not  yet  completed. 

The  nasal  and  pharyngeal  reflexes  are  particularly  weak  in 
children  born  before  term.  Abdominal  reflexes  are  almost  never 
present  in  the  premature;  in  fact  they  are  rarely  seen  in  the  new- 
born infant. 

Among  many  neurologists  the  opinion  is  prevalent  that  prema- 
turity predisposes  to  idiocy,  imbecility  and  epilepsy.  However,  it 
appears  in  these  instances  it  is  not  so  much  the  premature  birth 
that  is  responsible,  but  rather  there  seems  to  be  a  common  cause  lead- 
ing to  retarded  development  and  premature  expulsion  of  the  fetus. 

Cardiovascular  System.— As  compared  with  other  organs  the  heart 
is  relatively  well  developed.  That  the  heart  should  be  strong  is 
not  surprising,  as  from  the  first  months  of  pregnancy  the  precocious 
development  of  this  organ  is  found  to  be  in  complete  accord  with 
the  importance  of  its  function.  The  high  position  of  the  dia- 
phragm and  the  equality  of  the  diameters  of  the  thorax  causes 
the  long  axis  of  the  heart  to  lie  in  a  more  nearly  transverse  position. 
Because  of  this  position  the  apex  beat  is  found  in  the  fourth  inter- 
space, 0.5  to  1  cm.  outside  the  mammillary  line. 

The  variability  of  the  pulse-rate,  which  is  quite  marked  in  the 
premature  new  born,  ranges  from  90  to  200  per  minute,  with  an 
average  of  about  120.  This  variability  is  the  result  of  the  lack 
of  development  of  the  cardiac  inhibitory  centers. 

At  birth  the  thoracic  respirations  determine  a  considerable  flow 
of  blood  through  the  pulmonary  artery  to  the  lungs.  The  function 
of  the  ductus  arteriosus  ceases  at  this  time  and  the  blood  current  is 
diverted  from  the  foramen  ovale  through  the  tricuspid  orifice  into 
the  right  ventricle.  Within  twenty-four  to  forty-eight  hours  after 
birth  the  ductus  arteriosus  is  almost  completely  closed  normally, 
while  the  foramen  ovale  is  soon  completely  occluded  by  the  rapid 
growth  of  its  valvule.  If,  however,  the  ductus  arteriosus  is  not 
closed,  as  is  frequently  the  case  in  the  premature  infants,  due  to 
non-expansion  of  the  lungs  with  a  resulting  increased  resistance  in 
the  lesser  circulation,  cyanosis  may  result. 

The  heart  is  usually  only  secondarily  involved  in  asphyxial 
attacks,  the  tones  becoming  weak  and  slow  during  the  spells  of 
cyanosis.  The  heart  action  often  persists  for  hours  after  the  respi- 
ration ceases.  Myocardial  asthenia  in  the  premature  may  also 
result  in  cyanosis  and  is  frequently  accompanied  by  edema.  (See 
Cyanosis.)  General  circulatory  difficulties  may  also  be  the  cause 
of  subnormal  temperature  in  these  infants. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  67 

Blood-pressure  in  the  mature  at  birth  and  for  the  first  few  days 
of  life  is  low  and  in  the  prematures  and  weaklings  it  is  still  lower. 
In  the  new  born  the  pressure  ranges  around  80,  while  the  figures 
for  the  premature  and  the  weaklings  will  vary  from  60  to  70  mm. 
of  mercury  (Trumpp).1 

The  vascular  walls  in  the  premature  are  weaker  than  in  the  infant 
at  term  and  because  of  this  these  children  arc  subject  to  hemorrhage 
following  relatively  slight  traumata.  This  is  particularly  true  of 
the  intracranial  vessels  and  thus  we  see  that  hemorrhages  in  this 
region  are  relatively  more  frequent  in  the  premature. 

The  intracranial  hemorrhages  are  usually  followed  by  early 
death  and  in  many  instances  undoubtedly  these  are  interpreted  as 
respiratory  deaths  because  of  the  influence  of  pressure  on  the 
respiratory  center. 

This  tendency  to  hemorrhage  in  the  premature  in  some  cases  is 
due  to  deficient  coagulability  of  the  blood. 

In  a  study  of  the  new-born  Rodda2  found  by  his  method  that  the 
average  coagulation  time  was  seven  minutes,  with  a  normal  range 
between  five  and  nine  minutes. 

There  is  a  prolongation  of  coagulation  and  bleeding  times  from 
the  first  day  to  the  maximum  on  the  fifth  day  of  life,  with  a  return  to 
the  average  first-day  determination  time  before  the  tenth  day.  It 
is  significant  that  this  coincides  with  the  age  incidence  of  hemor- 
rhagic disease  and  cerebral  hemorrhage. 

In  icterus  neonatorum  normal  coagulation  and  bleeding  times 
were  found. 

Several  cases  of  melena  neonatorum  gave  markedly  prolonged 
coagulation  times— up  to  ninety  minutes— and  bleeding  times  of 
hours,  days  or  until  the  condition  was  controlled. 

Suspected  and  mild  cases  of  congenital  syphilis  gave  normal 
findings.     Severe  and  progressive  cases  gave  prolonged  times. 

Pfaundler3  found  a  low  alkali  reserve  in  debilitated  prematures 
and  believed  this  to  be  an  important  factor  in  the  low  immunity  to 
infection.  The  blood  also  shows  an  increased  viscosity  due  in  all 
probability  to  the  increase  of  water  loss  over  intake  during  the  first 
days.  Rusz4  has  also  suggested,  as  a  second  factor,  the  delayed 
tying  of  the  cord,  with  a  resulting  flow  of  blood  from  the  placenta, 
causing  a  relative  overloading  of  the  fetal  circulation. 

The  cell  content  of  the  blood  of  the  premature  does  not  differ 
greatly  from  that  of  the  new-born  infant,  though  it  does  possess 
certain  special  characteristics  (Kunckel).5 

1  Jahrb.  f.  Kinderh.,  1906,  63,  43. 

2  Am.  Jour.  Dis.  Child.,  April,  1920,  19,  269. 

3  Verhandl.  d.  Ges.  f.  Kinderh.,  Brcslau,  1904,  21,  24. 
*  Monatsschr.  f.  Kinderh.,  1911,  10,  360. 

6  The  Changes  in  the  Blood  of  the  Prematurely  Born  and  Weaklings,  Ztschr.  f. 
Kinderh.,  July  26,  1915,  13,  101. 


68  PHYSIOLOGY 

The  erythrocytes  are  slightly  less  in  number  and  diminish  readily 
under  the  influence  of  infections,  jaundice  and  edema.  Maero- 
cytes  and  microcytes  are  very  numerous  and  poikilocytosis  is  also 
often  observed .  Nucleated  erythrocytes  are  characteristic  of  the  blood 
of  the  premature  infant  and  the  farther  the  child  is  from  term  the 
more  numerous  are  these  nucleated  cells.  In  the  mature  infant 
nucleated  cells  are  only  found  during  the  first  few  days  of  life,  while 
in  the  premature  they  are  found  as  late  as  ten  days  after  birth. 
A  large  number  of  these  cells  is  incompatible  with  life.  They  re- 
appear quickly  with  the  onset  of  any  infection  and  are  slower  to 
disappear  when  the  temperature  is  subnormal.  With  redevelopment 
of  a  subnormal  body  temperature  during  the  first  weeks  of  life,  the 
nucleated  reds  tend  to  reappear. 

The  leucocytes  are  less  numerous  or  only  slightly  increased. 
Instead  of  12,000  to  13,000  leucocytes,  as  found  in  the  normal  full- 
term  new-born  infant,  there  are  on  the  average  8000  in  one  cubic 
millimeter  in  the  premature. 

The  differential  count  shows  a  high  percentage  of  mononuclears 
and  abnormal  elements,  such  as  mast  cells  (basophiles)  and  myelo- 
cytes. These  cells  possess  little  activity,  which  is  an  important 
factor  in  the  low  resistance  of  these  infants  to  disease.  What 
bearing  the  lowered  alkalinity  has  on  the  feeble  reaction  of  the 
white  cells  is  still  an  open  question.  The  reaction  to  infection  is, 
as  a  rule,  very  feebly  polynuclear  and  may  even  be  replaced  by 
one  of  transitional  forms  and  abnormal  elements,  myelocytes  and 
mast  cells,  as  if  the  hematopoietic  organs  were  only  capable,  in 
their  deficiently  developed  states,  of  putting  into  the  circulation 
immature  elements.  The  polynuclear  eosinophiles  are  fewer  in 
number  in  the  premature  and  disappear  when  an  infection  occurs. 
In  congenital  syphilis  they  are  usually  increased. 

While  in  the  normal  full-term  infants  the  hemoglobin  content 
gradually  sinks  and  at  the  end  of  the  fourth  week  amounts  to  about 
85  per  cent  (by  Sahli's  hemoglobinometer),  in  the  prematurely  born 
infants  its  value  at  this  time  is  50  to  60  per  cent;  therefore,  in 
prematurely  born  infants  there  is  a  distinct  and  very  early  hemoglo- 
bin impoverishment  of  the  blood,  which  reaches  its  maximum  in 
about  the  third  to  the  fourth  month.  While  the  hemoglobin  con- 
tent shows  a  marked  deviation  from  the  normal,  the  number  of 
erythrocytes  is  only  little  below  the  normal  and  therefore  the 
hemoglobin  content  of  the  individual  blood  corpuscle  is  considerably 
less  than  normal.  This  accounts  for  the  constant  and  early  devel- 
opment of  anemia  in  prematures  during  the  first  three  months  of 
life.  The  cause  of  this  hemoglobin  deficiency  seems  to  be  an 
insufficient  iron  content  of  the  premature's  blood,  which  is  easily 


:d  blood  cells. 

WL 

te  blood  cells. 

6,135,000 

7.512 

5,799,000 

5 .  755 

5,376,000 

8.572 

CHARACTERISTICS  OF   VARIOUS  ORGANS  69 

understood  when  we  recall  that  Hugouneng1  has  proven  that  the 
quantity  of  iron  stored  up  by  the  fetus  in  the  last  third  of  pregnancy 
is  twice  as  large  as  that  during  the  first  two-thirds. 

Liechtenstein's2  studies  on  a  large  number  of  premature  infants 
showed  a  considerable  degree  of  anemia  in  a  large  percentage  of 
his  cases. 

In  a  study  of  the  blood  findings  in  90  prematurely  born  infants 
(those  of  known  syphilitic  and  tuberculous  parentage  were  excluded ) 
in  greater  part  born  one  or  two  months  before  term,  Lichtenstein 
recorded  the  following  findings: 

In  10  cases  he  found: 

Age.  Hemoglobin. 

First  day  of  life  .  .  .  96 . 7 
Third  day  of  life  .  .  .  90 . 7 
Tenth  to  twelfth  day  of  life  85.8 

The  hemoglobin  and  red  cell  counts  were  relatively  those  of  the 
full  term,  showing  an  absence  of  congenital  anemia.  The  white 
blood  cells  were  below  the  averages  given  for  full-term  infants 
and  presented  an  absolute  leukopenia. 

There  was  also  a  more  marked  anisocytosis,  polychromatosis  and 
erythroblastosis  than  is  seen  in  the  blood  picture  of  the  full-term 
new-born. 

Subsequent  examinations  of  the  blood  in  19  premature  infants 
breast  fed  over  two  weeks  by  healthy  mothers  gave  the  following 
averages : 

Age. 
3  to  4  weeks 
2  months 
3 
4 
5 
6 

These  results,  when  compared  with  examinations  of  wet-nurses' 
infants,  showed  a  decided  oligochromemia  (controls  never  under 
55);  and  oligocythemia  (controls  rarely  under  4,000,000).  The  red 
cells  increased  toward  the  end  of  the  first  half  year  of  life.  The 
white  cell  counts  for  full-term  infants  usually  averaged  between 
10,000  and  12,000,  those  of  the  prematures  after  the  fourth  week 
between  7000  and  9000. 

There  is  also  a  constant  anisocytosis  and  anisochromemia  which 
changes  run  parallel  with  the  oligochromemia.  Erythroblasts  were 
found  in  some  cases  as  late  as  the  fourth  month. 

1  Compt.  Rend,  de  L'Acad.  des  Sc,  April,  1899,  128. 

2  Svenska  Lakaresa  As  Kapets  Handlinger,  Stockholm,  December  31,  1(J17,  No.  4, 
43. 


Hemoglobin. 

Red  blood  cells. 

White  blood  cells 

.      76.0 

4,023,000 

7,560 

.      50.5 

3,616,000 

8,720 

.      40.2 

2,945,000 

7,(14.' 

.     40.5 

3,065,000 

7,969 

.     44.0 

3,733,000 

7,969 

.      40.0 

3,740,000 

7,969 

70 


PHYSIOLOGY 


The  percentages  of  the  various  white  cells  do  not  vary  greatly 
from  the  picture  of  the  full-term  infant.  Metamyelocytes  were 
occasionally  seen  as  late  as  the  second  month.  The  figures  are 
tabulated  in  the  following  tables: 


WHITE   BLOOD   CELL  PERCENTAGES    (LICHTENSTEIN} 

. 

t-,         r           Neutrophile 

Day  °f           leucocytes, 

examination.        perc^nt.' 

Eosinophile 

leucocytes, 

per  cent. 

Small 

lymphocytes 

per  cent. 

Other         Large  mono- 
lymphocytes     nuclears, 
per  cent.     J     per  cent. 

.Metamye- 
locytes, 
per  cent. 

1st  day   . 
3d  day    .       . 
10  to  12  days 

45.8 
31.0 
27.9 

1.8 
3.1 
3.2 

11.6 

23.5 
20.3 

18.5 
27.5 
33.2 

8.2 

8.7 

11.2 

13.4 
5.9 
3.8 

white  blood  cell  percentages  in  the  later  months 
(lichtenstein). 


Leucocytes. 

Lymphocytes. 

Large  mononuclears. 

Eosin- 
ophile. 

Age  of 
infants. 

Max.       Min. 
per     1     per 
cent .       cent. 

No. 
cases. 

Max. 
per 
cent. 

Min. 
per 
cent. 

No. 
cases. 

Max. 
per 
cent. 

Min. 
per 
cent. 

No. 
cases. 

Per 
cent. 

0.5-1  month 
2 
3 
4-G       " 

33.5 
20.3 
41.5 
35.0 

5.8 

7.3 

9.5 

29.8 

5 

8 
6 
4 

76.5 
82.8 
79.8 
60.8 

51.5 
56.5 
44.0 
48.0 

5 
8 
6 
4 

14.5 
17.3 
12.0 
14.3 

1.0 
6.3 
3.5 

4.8 

5 

8 
6 
4 

2-3 
2-3 
2-3 
2-3 

Lande1  examined  a  group  of  70  prematures  born  from  the  sixth 
to  the  eighth  month  of  pregnancy,  with  weight  from  830  to  2500 
gm.  The  majority  were  fed  on  human  milk,  made  an  average 
monthly  gain  of  450  gm.,  and  were  relatively  free  from  infection 
and  congenital  lues.  The  results  of  examination  of  the  hemoglobin 
content  and  the  percentage  of  the  red  and  white  blood  cell  elements 
in  the  newly  born  prematures  during  the  first  weeks  of  life  are 
shown  in  the  following  table: 


No. 

cases. 

Hemoglobin. 

Erythrocytes. 

Erythro- 
blasts. 

White  blood  cells. 

Age  of 
infants. 

Max. 
per 

cent. 

Min. 

per 

cent. 

Com- 
monest 

value, 
per  cent. 

Max. 
cc. 

Min. 
cc. 

Com- 
monest 
value. 

Max. 

Min. 

Max. 

Min. 

Com- 
monest 
value. 

1  day 

2-4     " 
0-8     " 

12 

15 

0 

140 

135 

105 

100 

100 
100 

110-120 

125 

5.8 

6.7 
5.6 

3.8 

4.1 

4.0 

4.3-5.0 
4.6-5.4 

7000 

6700 
100 

400 

0 
0 

20,000 

16,000 
11,400 

3800 

3600 
6600 

10,000 

to 
15,000 
8,000 

to 
12,000 

i  Ztschr.  f.  Kinderh.,  1919,  22,  299. 


CHARACTERISTICS  OF  VARIOUS  ORGANS 


71 


Leukocytes. 

Lymphocytes. 

Large 
mononuclears. 

Myelo- 

Age of 

IB 

"S  55 

*B 

§  t 

O  i)     . 

Eosino- 

M..-i 

blasts 

and)  J 

myelo- 

infants. 

Si 

u 

a.  . 

I* 

0) 

o  o>    . 

u 
a 

0.    . 

- 

=  - 

3 

- 

philes. 

cells. 

••£ 

■  = 

~-     =  =  - 

J  a 

-  = 

=  ±  = 

=  £- 

cytes. 

«  u 

-  - 

H™§ 

gj  ;. 

-   i. 

=  >i 

CC   o 

«s 

6  $  r 

2 

§ 

3 

u 

3 

§ 

o 

3 

§ 

o 

1  day 

12 

54 

12 

40-50 

85 

39 

45-55 

12.5 

i 

7-10 

0 .5-1.5 

0-1.5 

3-12.5 

2-4     " 

15 

(14 

11 

40-55 

87 

30 

40-55 

12.0 

2 

.-,  10 

0-5  (I 

0-2.5 

_■     6  n 

6-8     " 

6 

08 

29 

65 

26 

8.0 

6 

0-2.0 

(i  2  0 

0     2.0 

From  these  tabulations  Lande  drew  these  conclusions:  Opposed 
to  the  findings  in  full-term  infants,  there  is  in  prematures  a  greater 
richness  of  nucleated  red  blood  corpuscles,  a  more  frequent  appear- 
ance of  myeloblasts  and  myelocytes  during  the  first  days  of  life, 
a  lesser  development  of  absolute  and  relative  leukocytosis,  and  a 
greater  number  of  immature  leukocyte  forms. 

The  blood  picture  from  the  third  week  of  life  to  the  age  of  six 
months  is  expressed  by  the  following  figures  (Lande) : 


Hemoglobin. 


Erythrocytes. 


Age  of 

No.  of 

infants. 

cases. 

Max., 
per  cent. 

Min., 
per  cent. 

Commonest 

value, 

per  cent. 

Max., 
Millions. 

Min., 

Millions. 

Commonest 

value, 
Millions. 

1 .0  month 

13 

105 

70 

80-85 

5.5 

3.3 

3.6-4.6 

1.5       " 

9 

95 

50 

60-70 

3.9 

2.7 

3.2 

2.0       " 

17 

80 

50 

60  70 

4.4 

2.4 

3.0-3.6 

2.5       " 

7 

80 

50 

60-65 

4.0 

2 . 3 

3.0-3.6 

3-3.5       " 

24 

80 

50 

60-70 

4.9 

2.4 

2.9-3.9 

4-4.5       " 

18 

75 

50 

60-70 

5.2 

2.7 

3.3-4.0 

5-5.5       " 

15 

85 

55 

65-75 

4.7 

3.4 

3.9-4.6 

Lande  noted  a  fall  in  the  hemoglobin  content  from  80  to  85  per 
cent  to  60  to  65  per  cent  in  the  third  month,  which  slowly  rises  to 
65  to  75  per  cent  in  the  sixth  month.  At  the  same  time  the  number 
of  erythrocytes  sinks  from  about  4,000,000  to  3,300,000,  in  order 
to  again  approach  the  normal  value  by  the  end  of  the  first  year. 

Nathan  and  Langstein1  have  found  the  blood  in  the  new-born 
very  low  in  antitoxic,  bactericidal  and  hemolytic  properties. 

Blood-sugar  determinations  in  three  healthy  prematures  fed  on 
mother's  milk  were   studied  by  Heller.2     In   no  case  was   sugar 


1  Ztschr.  f.  Kinderh.,  1919,  22,  299. 

2  Der  Blutzuckergehalt  bei  Neugeborenen  und  Fruhgeborenen  Kindern,  Ztschr.  f. 
Kinderh.,  1913,  9,  44. 


72  PHYSIOLOGY 

found  in  the  urine,  this  being  explained  by  the  fact  that  in 
no  instance  was  there  an  evident  hyperglycemia.  The  per- 
centage of  blood  sugar  noted  between  ten  and  a  half  and  twelve 
hours  after  birth  was  0.095,  0.089,  0.082;  these  figures  are  for 
infants  weighing  respectively  1500  gm.,  1380  gm.  and  930  gm.  The 
diets  were  increased  so  that  on  the  seventh  day  the  two  heavier 
infants  were  both  getting  160  gm.  while  the  smaller  was  given  80 
gm.  of  milk.  The  percentage  of  blood  sugar  was  then  noted; 
0.104  for  both  heavy  infants  (twins)  and  0.065  for  the  other.  All 
observations  were  taken  from  one -half  to  two  hours  after  the 
feeding.  There  was  a  steady  fall  in  blood  sugar  in  the  twins  until 
the  sixth  day. 

These  blood-sugar  findings  are  similar  to  those  of  Gotzky,1  who 
found  an  average  of  0.085  mg.  in  the  full-term  new  born,  somewhat 
lower  findings  in  prematures,  and  0.095  mg.  in  later  infancy,  as  com- 
pared with  0.102  mg.  in  later  years.  Because  of  the  relationship 
of  blood  sugar  to  diet,  comparative  studies  must  be  undertaken 
with  a  knowledge  of  the  quantity  and  quality  of  food  and  the  time 
to  the  meal. 

Lymphatic  System.— This  is  well  developed  and  does  not  differ 
materially  from  that  of  the  new  born,  unless  possibly  its  circulation 
is  slowed  as  a  result  of  the  slowing  of  the  general  circulation. 

Thymus  and  Thyroid  Glands.— These  organs  present  the  highest 
degree  of  development  of  any  glandular  structures.  In  fetal  life 
these  organs  contribute  to  the  formation  of  blood  and  during  the 
first  few  weeks  of  life  have  a  phagocytic  action. 

Genito-urinary  System.— In  the  female  the  labia  minora  usually 
overlap  the  labia  majora,  while  in  the  male  the  testicles  are  often 
high  in  the  inguinal  canal,  though  it  can  happen  that  they  are 
found  in  the  scrotum  as  early  as  the  seventh  month. 

An  examination  of  the  urine  of  the  premature  throws  but  little 
light  upon  the  metabolism  of  these  infants.  The  proportion  of 
ammonia  N  to  the  total  N  is  below  normal,  while  ~  is  increased. 
This  speaks  for  an  increase  in  the  processes  of  decomposition. 
Nobecourt  and  Lemaire2  found  that  the  freezing-point  of  the  urine 
of  prematures  was  lowered. 

The  amount  and  character  of  the  urine  during  the  first  few 
days  of  the  life  of  the  premature  depend  upon  the  intake  of  fluid, 
upon  the  absolute  body  weight  and  upon  the  absolute  and  relative 
amounts  of  water  within  the  body  tissues. 

If  the  quantity  of  fluids  taken  is  small  the  amount  of  urine 
secreted  is  proportionately  small.  When  the  quantity  is  larger,  as 
is  usually  the  case  if  the  infant  is  given  feedings  to  substitute 

i  Ztschr,  f.  Kinderh..  1913,  9,  44. 
2  Quoted  by  Pfaundler. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  73 

the  mother's  milk  and  frequent  feedings  of  water,  the  relative  as 
well  as  the  absolute  amount  of  urine  secreted  is  larger.  Cramer1 
found  that  with  an  abundant  supply  of  milk  during  the  first  few 
days  of  life  the  urinary  output  amounted  to  54  to  60  cc  for  every 
100  cc  of  milk  consumed. 

The  frequency  of  urination  during  the  early  days  of  the  prema- 
ture is  less  than  at  an  older  age.  While  the  infant  may  urinate 
during  its  passage  through  the  birth  canal  or  immediately  after, 
yet,  as  a  rule,  during  the  first  few  days  the  urinations  are  very 
infrequent,  at  most  three  or  four  and  more  often  only  one  or  two 
times  during  the  twenty-four-hour  period.  It  is  not  at  all  uncom- 
mon that  no  urine  is  passed  during  the  first  day.  This  failure 
to  urinate  during  the  first  day  of  life  is  not  of  much  moment,  but 
in  those  instances  of  absence  of  urination  for  as  long  as  four  days, 
as  have  been  reported,  some  anomaly  was  undoubtedly  present. 
With  the  increase  in  the  fluids  taken,  which  occurs  usually  on  the 
third  or  fourth  day,  the  frequency  of  urination  also  increases. 

During  the  period  of  greatest  concentration  the  reaction  of  the 
urine  is  strongly  acid.  As  it  becomes  more  dilute,  the  acidity 
becomes  less  marked. 

Albuminuria  is  a  symptom  shown  by  almost  all  infants  just 
after  birth,  full-term  as  well  as  premature.  The  length  of  time 
during  which  this  persists  is  short,  seldom  more  than  the  first 
few  days,  and  the  quantities  of  albumin  present  are  small:  0.25 
gm.  of  albumin  per  100  cc  of  urine  is  a  maximum  which  is  fre- 
quently reached  in  the  full-term  infant.  Yon  Reuss2  found  the 
urine  of  only  4  per  cent  of  new-born  infants  to  be  free  from  albumin 
during  the  first  four  days  of  life.  After  that  time  the  amount  of 
albumin  present  rapidly  falls,  unless  the  concentration  of  the  urine 
remains  high,  and  it  retains  the  turbidity  characteristic  of  infant 
urine,  when  the  albumin  persists  for  a  longer  period. 

Albumin  in  the  urine  of  the  new  born  would  seem  to  be  some- 
what of  a  physiological  condition,  certainly  having  no  relation  of 
a  causal  nature  to  the  infections  or  other  toxic  factors  of  the  later 
periods  of  life.  Albuminuria  at  this  time  seems  to  have  a  certain 
analogy  with  the  orthostatic  albuminuria  of  older  individuals,  both 
probably  to  be  accounted  for  by  circulatory  disturbances  of  the 
kidney.  Von  Reuss  believes  the  condition  is  most  easily  explain- 
able on  the  basis  of  circulatory  stagnation  which  occurs  in  a  more 
or  less  pronounced  degree  after  every  delivery.  Uric-acid  infarcts 
may  also  have  some  bearing  as  a  cause  of  albuminuria.  The 
deficient  blood  supply  of  the  kidney  and  the  lack  of  water  passing 
through  the  organ  as  a  result  of  the  small  quantity  taken  during 

1  Arch.  f.  Kinderh.,  1901,  22,  1. 

2  Verhandl.  d.  Ges.  f.  Kinderh.,  Miinster,  1912,  29,  145. 


74  PHYSIOLOGY 

the  first  few  days  of  life  probably  increases  the  amount  of  albumin 
passed. 

Nothmann1  found  milk  sugar  in  the  urine  of  premature  infants 
who  were  breast  fed,  and  he  reports  that  he  found  no  such  cases 
among  the  full-term  infants.  Sugar  was  found  by  Hoeniger2  in 
the  urine  of  several  infants  delivered  by  forceps.  It  was  excreted 
for  three  or  four  days  and  then  gradually  disappeared.  It  was 
believed  to  be  the  result  of  the  force  used  during  the  operative 
delivery. 

Acetone  bodies  are  found  in  small  quantities  in  the  urine  of  poorly 
nourished  and  underfed  weaklings. 

During  icterus  neonatorum  bilirubin  occurs  in  the  urine  in  the 
form  of  a  precipitate.  It  is  also  found  in  solution  in  septic  condi- 
tions and  in  hemorrhage  of  the  new  born. 

Creatin  and  creatinin  have  not  been  studied  in  the  premature. 

Occasionally  hyaline  casts  in  small  numbers,  often  covered  with 
urates,  are  seen.  These  are  probably  due  to  the  same  causes  as 
the  albumin  and  have  no  pathological  significance. 

Special  Senses.— Over  the  eyes  of  the  youngest  prematures 
occasionally  there  can  be  seen  more  or  less  well-marked  vestiges 
of  the  pupillary  membrane,  the  cornea  is  inclined  to  be  somewhat 
thicker,  the  anterior  chamber  less  deep  and  the  iris  less  pigmented. 
Strong  light  impressions  are  followed  by  reflex  closure  of  the  lids, 
but  sudden  movements  are  not  followed  by  such  closure,  as  the 
reflex  is  psychic,  depending  upon  fear. 

The  eye  movements  of  the  premature  infant  are  incoordinated, 
motion  being  most  often  in  a  horizontal  direction,  occasionally 
outward,  but  more  often  and  in  a  comparatively  strong  manner, 
inward.  It  is  not  uncommon  to  see  this  tendency  to  convergence 
persist  until  the  second  month.  The  light  reflex  is  present  before 
birth  and  the  pupil,  when  exposed  to  a  strong  light,  contracts  only 
to  dilate  again  in  two  or  three  seconds.  This  secondary  dilatation 
is  particularly  well  marked  in  the  premature  as  a  result  of  the  poor 
development  of  the  nerve  fibers,  which  are  easily  fatigued  (Fur- 
maim).3  The  convergence  reflex  is  absent  in  prematures  as  well 
as  in  the  more  mature  infant  because  fixation  does  not  occur. 

Skin  and  Adnexa.— The  skin  is  thin,  soft  and  usually  of  a  more  or 
less  vivid  red  appearance,  occasionally  of  a  peculiar  cyanotic  hue, 
and  the  transparent  dermis  allows  the  circulatory  network  to  be 
clearly  distinguished.  The  skin  is  partly  or  completely  covered 
with  lanugo  hairs  which  are  seen  most  commonly  between  the 

1  Monatschr.  f.  Kinderh.,  1909,  8,  377. 

2  Deutsche  med.  Wchnschr.,  1911,  500. 

3  Die  Reflexe  der  Siiuglinge.  Diss.,  Petersburg,  1903,  Loc.  cit.,  Gundobin,  Berlin, 
1912. 


CHARACTERISTICS  OF   VARIOUS  ORGANS 


75 


Fig.  27. — Embryological  eye  section.     (Normal  size  and  enlarged  5  diameters.) 

The  conjunctiva  has  reached  its  full  development  and  shows  subconjunctival  lymph- 
follicles  beginning  to  develop  into  separate  entities. 

The  cornea  is  still  in  the  developmental  stage  and  shows  some  interesting  conditions. 
The  corneal  epithelium  is  uniform  and  is  a  two-cell  layer  well  developed  and  without 
mitotic  figures.  Bowman's  membrane  is  just  beginning  to  be  differentiated  from  the 
anterior  corneal  stroma,  but  does  not  form  an  entity  as  yet.  The  development  of 
the  membrane  is  not  uniform  throughout  but  appears  in  scattered  areas  and  without 
continuity.  (This  would  tend  to  place  the  specimen  in  the  first  half  of  the  fifth 
month).  The  anterior  corneal  stroma  is  well  developed  and  is  dense.  The  posterior 
corneal  stroma  is  well  developed.  Both  stroma  show  fixed  corneal  cells.  Decemet's 
membrane  is  fully  developed  and  is  intact  from  angle  to  angle. 

The  anterior  chamber  has  begun  to  form  by  the  retraction  of  t  he  anterior  lens  capsule 
and  pupillary  membrane  from  the  posterior  surface  of  the  cornea  and  the  iris  is  push- 
ing into  the  anterior  chamber  in  front  of  the  lens.  The  chamber  angle  is  already 
differentiated  and  wide  spaces  exist  in  the  pectinate  ligament,  much  wider  than  in 
adult  life. 

The  iris  is  recognizable  as  a  separate  entity.  The  anterior  surface  is  smooth  and 
uniformly  covered  with  smooth  endothelium.  No  crypts  have  developed  as  yet. 
(This  speaks  for  an  age  of  less  than  six  months) .  The  iris  stroma  is  still  very  thin  ami 
loose,  but  is  well  vascularized.     The  retinal  pigment  epithelium  of  the  iris  is  differ- 


76 


PHYSIOLOGY 


entiated  and  well-developed,  although  the  posterior  layer  is  thinner  and  less  heavily 
pigmented  than  the  anterior.  The  sphincter  iridis  can  be  recognized  as  a  separate 
entity  and  already  fills  the  pupillary  margin  of  the  iris  fairly  well.  Individual 
dilator  fibers  are  present  but  the  muscle  as  a  whole  is  still  undeveloped. 

The  ciliary  body  is  still  small  and  is  posterior  to  the  position  occupied  in  adult  life. 
The  retinal  pigment  layer  and  the  ciliary  processes  are  well-developed  and  are  fairly 
well  anterior.  But  the  main  body  is  well  back,  is  thin,  and  is  still  undifferentiated 
into  its  component  parts.  Bruecke's  muscle  can  be  recognized,  although  it  has  not 
formed  into  the  complete  muscle  as  yet;  but  Mueller's  muscle  is  still  missing. 

The  lens  is  nearly  spherical  and  in  the  periphery  can  be  found  a  few  proliferating 
lens  fibers.  The  anterior  capsule  is  a  two-cell  layer  and  in  intimate  association  in  the 
pupillary  membrane  which  has  not  entirely  disappeared.  No  trace  of  vascularization 
remains.    The  posterior  capsule  is  missing.     No  zone  of  Zinn  fibers  can  be  found. 

The  vitreous  is  missing. 

The  retina  is  distinctly  behind  the  rest  of  the  eye  in  its  development.  A  definite 
separation  of  the  layers  is  present,  but  a  differentiation  of  rods  and  cones  has  not  yet 
taken  place.  Even  differentiation  of  the  cones  (the  first  to  appear  as  an  entity) 
cannot  be  recognized,  although  the  external  limiting  membrane  is  developed  and  in 
place.  Nerve  fibers  are  in  the  process  of  development  and  their  presence  has  swollen 
the  optic  nerve  head  to  its  usual  size.  There  is  much  glia  in  this  area.  Just  anterior 
to  the  optic  nerve  head  is  a  bit  of  hyaloid  artery  still  visible,  although  in  the  process 
of  absorption. 

The  optic  nerve  is  fairly  well  developed  although  there  is  more  glia  than  usual  in  an 
eye  of  this  size. 

The  chorioid  is  well  developed  and  is  fairly  well  vascularized. 

The  sclera  is  well  developed  but  is  rather  loose  in  structure.  (Description  of  speci- 
men by  Dr.  Harry  S.  Gradle,  Chicago.) 


Fig.  28. — Embryological  section  of  petrous  portion  of  temporal  bone.  (Normal 
size  and  enlarged  5  diameters).  Vertical  section  through  the  petrous  portion  of  the 
temporal  bone  of  a  fetus  of  five  and  a  half  months,  exposing  the  cochlea,  the  cochlear 
nerve,  two  semicircular  canals  and  adjacent  caseous  tissue. 


CHARACTERISTICS  OF   VARIOUS  ORGANS  77 

shoulder  blades,  but  also  frequently  upon  the  face  and  upon  the 

extensor  surfaces  of  the  extremities.  There  is  also  noted  extensive 
milium  and  flaccidityof  the  auricleand  ahe  nasi,  whose  cartilage  is 
not  properly  developed. 

Icterus  is  usually  more  pronounced  than  at  term  and  erythema 
is  slower  to  disappear.     If  hypothermia  develops  the  redness  of 

the  skin  usually  fades. 

The  absence  of  subcutaneous  fat  betrays  itself  by  an  angular 
appearance  of  the  face,  the  chin  is  pointed,  the  head  is  small  and 
narrow  and  the  wrinkles  of  the  skin  impart  an  oldish  appearand  e  to 
the  face  which  is  especially  marked  after  a  few  days  when  the  loss 
of  weight  has  been  material  and  the  skin  often  hangs  in  folds  over 
the  muscles  and  bones.  Not  infrequently  the  skin  appears  glossy 
as  if  on  tension  and  this  is  seen  especially  in  small  prematures  in 
the  presence  of  sclerema  and  scleredema.  Patches  of  skin  may  be 
absent,  especially  over  the  heels. 

The  hairs  on  the  scalp  are  short  and  feebly  colored,  the'nails  are 
often  poorly  developed  and  do  not  reach  the  end  of  the  fingers  or 
toes  and  the  nose  is  covered  with  small  white  comedones.  The 
navel  is  closer  to  the  symphysis  than  at  term. 

Mammary  Glands.— The  mammary  glands  are,  as  a  rule,  poorly 
developed,  usually  not  palpable  and  particularly  in  the  younger 
prematures  do  not  often  attempt  to  secrete  milk.  If  fluid  is  present, 
as  it  may  be  in  the  older  prematures,  it  usually  makes  its  appear- 
ance about  the  eighth  day,  is  most  abundant  up  to  the  fifteenth 
day  and  may  last  until  the  third  month.  It  is  equally  common 
in  either  sex.  In  most  cases  the  secretion  amounts  to  only  a  few 
drops,  but  occasionally  larger  quantities  are  seen. 

Skeletal  Development.— The  lack  of  exact  anatomical  data  as  to 
the  skeletal  development  of  the  premature  infant  has  caused  the 
author  to  resort  to  the  use  of  roentgenographie  studies.  The 
stage  of  ossification  of  the  skeleton  of  the  fetus  as  observed  in 
roentgenograms  is  of  considerable  practical  importance  in  deter- 
mining the  age  of  the  fetus.  In  addition  observation  by  the  roentgen- 
ographie method  is  more  reliable  than  determination  of  age  based  on 
length  and  other  measurements,  since  osseous  development  is  more 
regular  and  offers  many  more  factors  for  consideration.  Pathology 
may  often  be  readily  recognized.  Our  studies  thus  far  have  shown 
that  in  the  early  months  more  accurate  determination  is  possible 
than  in  the  later  months,  because  many  more  new  centers  appear  in 
the  first  months,  and  the  time  of  appearance  is  more  constant. 

The  study  of  the  roentgenograms  for  diagnostic  purposes  discloses 
that  the  cephalad  segments,  including  the  upper  axial  skeleton  and 
upper  extremities,  are  far  more  constant  as  to  time  of  development 
of  their  osseous  centers  than  the  caudad  segments  and  those  of  the 


78 


PHYSIOLOGY 


lower  extremities.     This  should  be  borne  in  mind  in  making  com- 
parative  studies. 

The  figures  as  to  length  and  other  measurements  of  the  fetus 
have  been  discussed  earlier  (p.  29).  Basing  our  facts  on  the  roent- 
genographic  studies  of  a  series  of  55  normal  cases,  whose  ages 
were  determined  from  the  history  of  menstruation  and  pregnancy 
and  from  their  measurements,  the  normal  process  of  development 
of  the  human  skeleton  was  found  to  be  as  follows: 


Fig.  29. — Development  of  centers  in  weeks.  Diagram  showing  osseous  develop- 
ment of  infant  at  full  term,  and  development  of  ossification  centers  in  weeks.  Centers 
shown  which  are  frequently  absent  at  birth:  (1)  head  of  tibia;  (2)  coccyx.  Centers 
omitted  in  outline:  (1)  sternum;  (2)  hyoid. 


CHARACTERISTICS  OF  VARIOUS  ORGANS 


79 


Other  Measurements  of  the  Fetus.— Von   Winckel    regards    the 

circumference  of  the  head  as  of  importance  for  the  diagnosis  of  the 
age  of  the  fetus  and  gives  the  following  figures: 


4th  month   . 

.      .      10-14  cm. 

8th  month   . 

.      .     25-30  cm 

5th       "        .      . 

.      .      13-18     " 

9th       "        .      . 

.       .      29  33     " 

6th       "        ... 

.      .      19-24     " 

10th       "        .      . 

.      .      32-37     " 

7th       "        .      . 

.      .     23-28    " 

The  weight  is  entirely  unreliable  for  the  estimation  of  the  age  of 
the  fetus,  because  it  is  subject  to  too  many  variations  and  is  much 
influenced  by  the  mother's  general  condition,  and  more  especially 
by  her  diet. 

Thus,  it  is  seen  that  even  the  length,  which  up  to  this  time  has 
been  regarded  as  the  most  reliable  criterion  for  the  determination  of 
the  age  of  the  fetus,  has  many  shortcomings  and  may  result  in  an 
error  of  several  weeks. 

The  ossification  of  the  human  skeleton  begins  in  the  upper  part 
of  the  body  and  spreads  very  rapidly  in  both  directions. 


Fig.  31 

Figs.  30  and  31.  —  Roentgenogram  Fig.  30  and  diagram  P'ig.  31  of  fetus  at  seven  weeks, 

actual  size. 

Seventh  Week. — The  first  centers  of  ossification  develop  in  the 
clavicles  in  the  sixth  to  seventh  week  of  intra-uterine  life  (Kreibel- 
Mall,  Rauber-Kopsch1),  but  they  do  not  become  visible  in  the 
roentgenograms  until  in  the  seventh  week.  The  ossification  center 
appears  in  the  middle  of  each  clavicle  and  spreads  rapidly  in  both 
directions. 

Soon  after  the  ossification  has  started  in  the  clavicle  one  center 
appears  in  each  half  of  the  mandible. 

Outside  of  these  centers  of  ossification  usually  no  other  centers, 
except  occasionally  that  of  the  maxilla,  are  visible  in  roentgenograms 
of  the  seven  weeks'  old  fetus. 


1  Lehrbuch  der  Anatomie  des  Menschen,  Thieme,  Leipzig,  1914,  2,  ed.  10. 


80  PHYSIOLOGY 

Eighth  Week.—  Osseous  development  makes  rapid  progress  in  the 
eighth  week,  and  a  large  number  of  centers  of  ossification  become 
visible  at  this  time. 


Figs.  32  and  33.  — Roentgenogram  Fig.  32   and  diagram   Fig.  33  of  fetus  at  eight 

weeks,  actual  size. 

The  following  bones  show  centers  of  ossification  demonstrable 
in  roentgenograms. 

Skeleton  of  the  head:  The  squamous  portion  of  the  occipital 
bone  and  superior  maxilla.  In  the  latter  the  ossification  begins 
soon  after  that  of  the  mandible,  the  center  appearing  above  the 
region  where  the  alveolus  of  the  incisor  tooth  is  later  located. 

TABLE    3.— TIME    OF   APPEARANCE    OF   CENTERS    OF    OSSIFICATION 

HEAD 

Mandible 7th  week 

Occipital  bone  (squamous  portion) 8th  week 

(lateral  and  basilar  portion) 9th  to  10th  week 

Superior  maxilla 8th  week 

Temporal  bone  (petrous,  mastoid  and  zygoma) 9th  week 

Sphenoid  (inner  lamella  of  pterygoid  process) 9th  week 

(great  wings) 10th  week 

(lesser  wings) 13th  week 

(anterior  body) 13th  to  14th  week 

Nasal  bone 10th  week 

Frontal  bone 9th  to  10th  week 

Bony  labyrinth      .                        17th  to  20th  week 

Milk  teeth  (rudiments) 17th  to  28th  week 

Hyoid  bone  (greater  cornua) 29th  to  32d    week 

Usually  no  centers  of  ossification  are  present  in  the  axial  skeleton 
in  this  week. 

Shoulder  girdle:  In  the  scapula  a  center  of  ossification  usually 
appears  in  the  eighth  week,  sometimes  in  the  ninth  week.  The 
center  corresponds  to  the  position  of  the  middle  of  the  spine  of 
the  scapula. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  M 

Upper  extremity:  The  humerus  is  the  first  bone  of  the  free 
extremities  to  show  a  center  of  ossification,  which  appears  in  the 
diaphysis  early  in  the  eighth  week.  Radius  and  ulna  follow  in 
the  order  given,  the  centers  appearing  very  soon  after  those  of  the 
humerus. 

The  ribs  begin  their  ossification  in  the  eighth  week,  an  ossifi- 
cation center  appearing  in  the  region  of  the  angle  and  extending 
slowly  toward  the  veretebral  column,  but  rapidly  in  the  opposite 
direction.  The  fifth,  sixth  and  seventh  ribs,  which  ossify  first, 
are  visible  in  this  period.  From  this  region  the  process  of  uni- 
fication progresses  with  equal  rapidity  both  cephalad  and  caudad. 
The  last  ribs  to  ossify  are  usually  the  first  pair.  Shortly  before 
the  first  pair,  the  twelfth  pair  usually  ossifies,  but  this  is  very 
irregular  and  we  found  it  absent  in  several  of  our  cases  in  old 
fetuses  although  other  bones  of  the  body  and  all  the  other  ribs 
were  very  well  developed. 

TABLE   4.— TIME   OF   APPEARANCE   OF  CENTERS   OF   OSSIFICATION 

BODY 

Clavicle  (diaphysis; 7th  week 

Scapula 8th  to    9th  week 

RIBS. 

Ribs,  5th,  6th,  7th 8th  to  9th  week 

2d,  3d,  4th,  8th,  9th,  10th,  11th 9th  week 

1st 10th  week 

12th  (very  irregular) 10th  week 

STERNUM. 

Sternum 21st  to  24th  week 

UPPER   EXTREMITY. 

Humerus  (diaphysis) 8th  week 

Radius  (diaphysis) s'h  week 

Ulna  (diaphysis) 8th  week 

Phalanges,  terminal 9th  week- 
basal,  3d  and  2d 9th  week 

basal,  4th  and  1st 10th  week 

basal,  5th 11th  to  12th  week 

middle  3d,  4th,  2d 12th  week 

middle  5th 13th  to  16th  week; 

Metacarpals,  2d  and  3d 9th  week 

4th,  5th,  1st 10th  to  12th  week 

Lower  extremity:  Centers  of  ossification  may  be  occasionally 
seen  in  the  diaphyses  of  the  femur,  but  usually  they  become  visible 
in  the  ninth  week.  The  femur  is  the  first  to  show  a  center,  the 
tibia  starting  in  its  ossification  a  little  later,  and  the  fibula  following 
very  soon  after  the  tibia. 

Ninth  If >f A-.— Portions  of  the  hand  and  of  the  foot  enter  the 
stage  of  ossification,  these  being  the  most  important  new  develop- 
ments in  this  week. 
6 


82  PHYSIOLOGY 

The  following  additional  centers  of  ossification  are  visible  in  the 
head:  Inner  lamella  of  the  pterygoid  process  of  sphenoid  and 
mastoid  portions  of  the  temporal  bone.  The  zygomatic  process  of 
the  temporal  bone  begins  to  cast  a  shadow,  its  shape  being  some- 
what pointed  anteriorly  and  somewhat  convex  externally,  thus 
resembling  a  needle.  Bony  trabecular  are  often  seen  in  the  poste- 
rior root  of  the  mastoid  process.  The  superior  maxilla  forms  at 
this  time  a  simple  triangular  plate,  the  base  of  which  is  parallel 
to  the  margin  of  the  maxilla,  the  apex  pointing  toward  the  root  of 
the  nose.  The  malar  bone  may  become  visible  toward  the  end  of 
this  week  or  during  the  next  week. 

TABLE  5.— TIME   OF  APPEARANCE   OF  CENTERS   OF  OSSIFICATION 

VERTEBRA 

Arches,  all  cervical  and  upper  1  or  2  dorsal 9th  week 

all  dorsal  and  1  or  2  lumbar 10th  week 

lower  lumbar 11th  week 

upper  sacral 12th  week 

4th  sacral 19th  to  25th  week 

Bodies  from  2d  dorsal  to  last  lumbar 10th  week 

from  lower  cervical  to  upper  sacral 11th  week 

from  upper  cervical  to  lower  sacral 12th  week 

5th  sacral 13th  to  28th  week 

1st  coccygeal 37th  to  40th  week 

structural  arrangement 13th  to  16th  week 

odontoid  process  of  axis 17th  to  20th  week 

Costal  processes,  6th  and  7th  cervical 21st  to  33d    week 

5th  cervical 33d    to  36th  week 

4th,  3d,  2d  cervical 37th  to  40th  week 

Transverse  processes,  cervical  and  dorsal 21st  to  24th  week 

lumbar 25th  to  28th  week 

Axial  skeleton:  Arches  of  all  the  cervical  and  upper  one  or  two 
dorsal  vertebrae  show  centers  of  ossification,  usually  no  centers  for 
bodies  being  visible.  One  center  develops  in  each  arch,  the  process 
beginning  in  the  first  cervical  vertebra  and  proceeding  caudally. 

Shoulder  girdle:  The  acromion  process  of  the  scapula  begins  to 
ossify  in  this  week.  The  first  formations  of  these  centers  are  diffi- 
cult to  study  in  roentgenograms  on  account  of  their  small  size, 
but  the  later  stages  can  be  easily  demonstrated.  Development  of 
the  centers  of  ossification  in  terminal  phalanges  is  followed  by  the 
appearance  of  centers  in  the  metacarpals  which  become  visible  in 
the  ninth  to  tenth  week.  The  following  is  the  order  of  ossification 
in  the  metacarpals:  second,  third,  fourth,  fifth,  first,  of  which  the 
second  and  the  third  are  usually  visible  in  the  ninth  week. 

Ribs:   All  the  ribs,  except  the  first  and  the  twelfth  cast  shadows. 

Pelvic  girdle :  The  ilium  usually  appears  in  this  week,  rarely  at  the 
end  of  the  eighth  week.  Ossification  begins  in  the  region  of  the 
greater  sacrosciatic  foramen  and  near  the  acetabulum. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  83 

Lower  extremity:  Centers  of  ossification  in  femur,  tibia  and 
fibula  are  seen.  Centers  begin  to  develop  in  the  phalanges,  the 
first  one  being  a  center  for  the  diaphysis  of  the  terminal  phalanx 
of  the  big  toe.  Diaphyses  of  the  metatarsals  follow  in  the  same 
sequence  and  almost  at  the  same  time  as  corresponding  portions  of 
the  hand,  but  with  far  less  regularity. 

TABLE    ().  — TIME    OF   APPEARANCE   OF   CENTERS   OF    OSSIFICATION 

PELVIC    GIRDLES. 

Ilium 9th  week 

Ischium  (descending  ramus) 16th  to  17th  week 

Os  pubis  (horizontal  ramus) 21st  to  28th  week 

LOWER    EXTREMITY. 

Femur  (diaphysis) 8th  to  9th  week 

(distal  epiphysis)         35th  to  40th  week 

Tibia  (diaphysis) 8th  to  9th  week 

(proximal  epiphysis) 40th  week 

Fibula 9th  week 

Os  calcis 21st  to  29th  week 

Astragalus 24th  to  32d    week 

Cuboid 40th  week 

Metatarsal,  2d  and  3d 9th  week 

4th,  5th  and  1st 10th  to  12th  week 

Phalanges,  terminal  1st 9th  week 

terminal  2d,  3d,  4th 10th  to  12th  week 

terminal  5th 13th  to  14th  week 

basal  1st,  2d,  3d,  4th,  5th 13th  to  14th  week 

middle  2d 20th  to  25th  week 

middle  3d 21st  to  26th  week 

middle  4th 29th  to  32d    week 

middle  5th 33d    to  36th  week 

Tenth  Week.— Comparatively  few  new  centers  of  ossification  are 
added  in  this  week. 

Skeleton  of  the  head:  Xasal  bone  and  frontal  bone  show  centers 
of  ossification.     The  great  wing  of  the  sphenoid  becomes  visible. 

Axial  skeleton:  Bodies  of  the  vertebrae  begin  to  cast  shadows. 
The  process  starts  in  the  bodies  of  the  lower  dorsal  vertebra?,  pro- 
gressing from  this  region  with  unequal  rapidity  in  both  directions. 
Usually  the  lower  ten  dorsal  and  all  the  lumbar  vertebra*  show 
centers  of  ossification  in  their  bodies  in  this  week.  The  process  of 
ossification  of  the  arches,  progressing  downward,  has  become  more 
or  less  advanced  in  all  the  thoracic  vertebra3,  invading  occasionally 
the  upper  lumbar  region. 

Shoulder  girdle:  Ossification  of  the  scapula  spreads  to  the 
supraspinous  fossa. 

Upper  extremity:  Diaphyses  of  basal  phalanges  of  fingers  develop 
centers  of  ossification,  the  following  being  the  sequence:  third, 
second,  fourth,  first  and  fifth.  Of  these,  usually  the  third,  only, 
shows  a  center  in  this  week. 


84 


PHYSIOLOGY 


Ribs:  At  this  time  ossification,  as  a  rule,  is  seen  in  all  the  ribs, 
the  twelfth  behaving  very  irregularly.  It  was  found  absent  in 
some  comparatively  old  fetuses  far  beyond  the  tenth  week. 

Lower  extremity :  Beginning  with  this  week  centers  of  ossification 
are  present  also  in  the  terminal  phalanges  of  the  second  and  of  the 
third  toes. 


Fig.  34 


Fig.  35 


Figs.  34  and  35. — Roentgenogram  Fig.  34  and  diagram  Fig.  35  of  fetus  at  ten  weeks, 

actual  size. 


Eleventh  to  Twelfth  Week.— In  this  period  almost  as  many  centers 
of  ossification  are  present  in  the  fetal  skeleton  as  at  the  time  of 
birth,  so  that  but  few  are  added  during  the  period  of  development 
following  the  third  month,  and  further  changes  in  the  fetal  skeleton 
consist  mostly  of  growth  of  the  centers  of  ossification,  of  their  fusion 
and  of  the  formation  of  the  internal  structure  of  the  bones.  A 
fine,  somewhat  irregular,  medullary  cavity  forms  in  the  long  bones, 
usually  being  seen  first  in  the  tibia. 

Skeleton  of  the  head :  The  tympanic  ring  usually  becomes  visible 
in  this  week,  rarely  at  the  end  of  the  eleventh  week.  In  pictures 
taken  from  the  side,  its  shadow  lies  between  the  angle  of  the  man- 
dible and  the  basilar  portion  of  the  occipital  bone.  The  median 
lamella  of  the  pterygoid  process  reaches  considerable  size  and  is 
visible  as  a  hook-shaped,  curved  plate  with  concavity  posteriorly, 
lying  behind  the  lower  portion  of  the  perpendicular  part  of  the 
palate  bone.  The  malar  bone  joins  the  end  of  the  zygomatic 
process  of  the  superior  maxilla  and  that  of  the  temporal  bone. 


CHARACTERISTICS  OF  VARIOUS  ORGANS  85 

Four  centers  are  now  present  in  the  occipital  bone.  The  anterior 
sphenoidal  body  begins  to  ossify. 

Axial  skeleton:  Ossification  of  the  arches  invades  the  lower  lum- 
bar region.  The  ossification  of  the  bodies  now  appears  in  the  lower 
cervical  region  and  in  the  upper  part  of  the  sacrum,  the  inter- 
mediary bodies  having  been  visible  previously.  There  are,  how- 
ever, considerable  variations  in  the  time  of  appearance  of  centers 
of  ossification  in  the  sacral  vertebra?. 

Shoulder  girdle:  Xo  new  centers  develop,  the  old  ones  increasing 
in  size. 

Upper  extremity:  The  diaphyses  of  all  the  basal  phalanges  cast 
shadows.  Middle  phalanges  of  the  third,  fourth  and  occasionally 
of  the  second  finger  develop  centers  of  ossification  in  their  diaph- 
yses.    The  middle  phalanx  of  the  fifth  finger  ossifies  much  later. 


Fig.  36. — Photograph  (a)  and  roentgenogram  (b)  of  transparent  specimens  of  fetus 
at  ten  weeks.     One-half  actual  size. 

Up  to  the  end  of  the  third  month  the  bony  diaphyses  of  the  humerus, 
radius  and  ulna  remain  longer  and  thicker  than  the  corresponding 
bones  of  the  lower  extremity. 

Pelvic  girdle :  Either  in  this  period  or  shortly  after,  a  third  center 
of  ossification  develops  in  the  ilium,  being  situated  ventrally  from 
the  fused  first  and  second  centers.  There  is  a  marked  irregularity 
in  the  time  of  appearance  of  the  third  center  of  the  ilium,  since 
occasionally  it  may  appear  almost  three  weeks  after  this  time. 

Lower  extremity:  The  terminal  phalanges  of  the  fourth  and 
fifth  toes  usually  develop  centers  of  ossification;  in  the  fifth,  how- 
ever, the  center  may  occasionally  appear  as  late  as  in  the  thirteenth 
week.  The  bony  diaphysis  of  the  femur,  which  up  to  this  time  has 
been  shorter  and  thinner  than  the  bony  diaphysis  of  the  humerus, 
has  almost  reached  the  length  of  the  latter,  remaining,  however, 
still  somewhat  thinner. 


Fig.  37 


Fie.  3S 

Figs.  37  and  38.— Roentgenogram  Fig.  37  and  diagram  Fig.  38  of  fetus  at  eleven  to 

twelve  weeks,  actual  size. 


CHARACTERISTICS  OP  VARIOUS  ORGANS 


87 


Thirteenth  to  Sixteenth  Week.— Characteristic  in  the  osseous 
development  of  this  period  is  the  appearance  of  structural  arrange- 
ment in  the  bodies  of  some  vertebrae  and  the  presence  of  centers 
of  ossification  in  the  diaphyses  of  all  of  the  long  bones  of  the  hand 
and  of  the  foot,  except  the  middle  phalanges  of  toes. 

Skeleton  of  the  head:  The  lesser  wing  of  the  sphenoid  is  visible 
at  the  beginning  of  this  period.  The  posterior  body  of  the  sphenoid 
appears  about  the  fourteenth  week. 


Fig.  39 


Fig.  40 


Figs.  39  and  40. — Roentgenogram  Fig.  39  and  diagram  Fig.  40  of  fetus  at  thirteen  to 
sixteen  weeks,  one-half  actual  size. 


Axial  skeleton:  At  the  end  of  this  period  all  the  vertebra',  with 
the  exception  of  first  and  second  lower  sacral  and  the  coccygeal, 
have  at  least  one  center  of  ossification.  Arches  are  ossified  also 
in  the  upper  sacral  region  and  the  bodies  from  the  upper  cervical 
down  to  the  lower  sacral  region.  Structural  arrangement  becomes 
visible  in  the  bodies  of  some  vertebrae.  Upper  and  lower  plate, 
casting  denser  shadow,  become  differentiated.  A  zone  of  lighter 
shadow  is  seen  between  these  two  plates  and  in  the  central  portion 


ss 


PHYSIOLOGY 


of  the  body  a  flat,  darker  shadow  appears.  The  greatest  diameter 
of  this  darker  shadow  corresponds  to  the  longitudinal  axis  of  the 
fetus  in  lumbar  and  lower  dorsal  vertebra?;  in  other  dorsal  vertebrae 
it  lies  horizontally.  These  shadows  appear  in  the  bodies  of  the 
vertebrae  in  the  region  in  which  the  primary  centers  made  their 
first  appearance. 

Upper  extremity:  In  the  fifteenth  to  sixteenth  week  a  center  of 
ossification  appears  in  the  diaphysis  of  the  middle  phalanx  of  the 
fifth  finger,  so  that  at  this  time  the  diaphyses  of  all  the  long  bones 
of  the  hand  possess  centers  of  ossification. 

Pelvic  girdle:  At  the  end  of  this  period  or  somewhat  later  a 
center  becomes  visible  in  the  descending  ramus  of  the  ischium. 
Instead  of  one  center,  two  separate  centers  may  develop  in  this 
portion  of  the  innominate  bone  and  they  may  remain  separate  for 
a  long  time  afterward. 


Fig.  41.- 


-  Roentgenograms  of  skull   showing  ossification  centers  at   (a)    eleven   to 
twelve  weeks  and  (b)  thirteen  to  sixteen  weeks,  actual  size. 


Lower  extremity:  In  the  thirteenth  week  a  center  of  ossifica- 
tion develops  in  the  diaphysis  of  the  terminal  phalanx  of  the  fifth 
toe,  if  it  did  not  appear  earlier.  In  the  fourteenth  Meek  ossifica- 
tion in  the  basal  phalanges  begins,  first  in  the  big  toe,  and  proceeds 
toward  the  fibular  side  in  other  toes,  and  at  the  end  of  this  period 
it  usually  reaches  the  last  toe. 

Seventeenth  to  Twentieth  Week.— In  this  period  the  bony  labyrinth 
first  appears  and  bone  tissue  begins  to  be  formed  in  the  rudiments 
of  the  milk  teeth. 

Skeleton  of  the  head:  Several  new  centers  of  ossification  appear 
in  the  petrous  portion  of  the  temporal  bone,  but  they  do  not  show 


CHARACTERISTICS  OF  VARIOUS  ORGANS  89 

well  in  roentgenograms.  The  bony  labyrinth  begins  its  development. 
In  the  rudiments  of  milk  teeth,  bone  tissue  begins  to  be  formed 
and  casts  a  shadow.     The  process  starts  in  the  lower  incisors. 

Axial  skeleton:  A  center  of  ossification  appears  in  the  odontoid 
process  of  the  axis.  The  darker  shadows  in  the  bodies  of  the 
vertebrae  become  more  distinct  and  external  formation  and  internal 
structure  of  osseous  bodies  of  vertebra1  become  visible  in  roentgeno- 
grams.    Ossification  of  the  arches  may  reach   the  fourth   sacral 


Fig.  42.— Photomicrograph  of  cross  section  of  arm  of  twenty-two  weeks  :• 
Enlarged  6  diameters.       Small  figure  actual  size. 

vertebra  at  the  end  of  this  period,  although  this  frequently  occurs 
later. 

Pelvic  girdle:  The  twentieth  week  is  the  earliest  time  of  appear- 
ance of  a  center  in  the  horizontal  ramus  of  the  pubic  bone;  this, 
however,  varies  between  the  twentieth  and  the  twenty-eighth  week. 
The  center  is  located  near  the  margin  of  the  obturator  foramen, 
two  centers  developing  occasionally. 

Lower  extremity:    In  the  twentieth  week  a  center  of  ossification 


90 


PHYSIOLOGY 


may  develop  in  the  middle  phalanx  of  the  second  toe,  but  this 
usually  occurs  in  the  twenty-first  to  the  twenty-fourth  week  and 
frequently  even  later  than  this.  On  the  whole,  there  are  marked 
differences  and  also  individual  variations  in  the  time  of  appear- 
ance of  centers  of  ossification,  and  also  in  the  sequence  of  ossi- 
fication in  the  phalanges  of  toes,  especially  in  the  basal  phalanges 
and  even  more  so  in  the  middle  phalanges.     In  the  hand,  however, 


Fig.  43.— Photograph  of  cross-section  of  forearm  of  twenty-two  weeks  fetus. 
Enlarged  6  diameters.     Small  figure  actual  size. 

the  sequence  of  ossification  in  the  phalanges  is  far  more  constant 
and  the  time  of  appearance  of  the  centers  is  much  less  changeable 
than  that  of  the  centers  in  the  phalanges  of  toes. 

Twenty-first  to  Twenty-fourth  Week. — In  this  period  ossifica- 
tion usually  starts  in  the  tarsus,  os  calcis  being  the  first  to  show 
a  center  of  ossification.  The  sternum  begins  to  develop  by  several 
centers  of  ossification,  but  there  are  considerable  variations  in  the 


CHARACTERISTICS  OF  VARIOUS  ORGANS 


01 


arrangement  and  size  of  these  centers  and  also  in  the  time  of  their 
appearance. 

Skeleton  of  the  head:  The  superior  maxilla  shows  a  large  amount 
of  spongiosa.  Toward  the  twenty-fourth  week  the  alveolar  por- 
tion of  the  superior  maxilla  begins  to  overhang  the  level  of  the 
palatal  plate,  but  develops  as  a  real  process  only  during  the  cutting 
of  the  teeth. 

Axial  skeleton :  The  costal  process  of  the  sixth  cervical  vertebra 
starts  in  its  ossification.  Shadows  of  transverse  processes  are  seen 
in  vertebra3  down  to  the  twelfth  dorsal. 


Fig.  44 


Fig.  45 


Figs.  44  and  45. — Roentgenogram  Fig.  44  and  diagram  Fig.  45  of  fetus  at  seventeen 
to  twenty  weeks,  one-third  actual  size. 


Upper  extremity:  In  this  period  the  ossified  portion  of  the 
diaphysis  of  the  humerus  reaches  the  articular  ends  and  begins  to 
overlap  these  so  that  at  the  distal  end  of  the  humerus  both  fossae 
(olecranon  and  cubital)  and  ulna  and  olecranon  become  visible, 
and  later,  on  the  proximal  end  of  the  humerus  an  indication  of 
medial  and  posterior  portion  of  the  neck  appears. 

The  sternum  begins  its  ossification.  Usually  one  center  forms 
in   the  manubrium  first  and  this  is  followed  soon  afterward  by 


92 


PHYSIOLOGY 


several  centers  in  the  body  of  the  sternum.  The  centers  form  a 
longitudinal  row  first,  and  soon  they  assume  a  round  or  elliptical 
form.  Not  seldom  the  first  centers  of  ossification  appear  in  the 
upper  part  of  the  body  between  the  second  and  the  third  costal 
cartilages.  The  position  of  the  ossification  centers  of  the  sternum 
corresponds  usually  to  the  level  of  the  intercostal  spaces. 


IV 

^r 

a 

>    * 

Fi<;.  40  Fig:  47 

Figs.  46  and  47. — Roentgenogram  Fig.  46  and  diagram  Fig.  47  of  fetus  at  twenty-five 
to  twenty-eight  weeks,  one-fourth  actual  size. 


Lower  extremity:  A  center  of  ossification  develops  in  os  calcis, 
its  appearance  being  occasionally  delayed  by  from  four  to  eight 
weeks.  Sometimes  it  is  followed  by  the  appearance  of  a  center  in 
the  astragalus.  The  middle  phalanx  of  the  second  toe,  and  occa- 
sionally that  of  the  third  toe,  acquire  a  center  of  ossification  in 
their  diaphyses. 

Tiventy-fifth  to  Twenty-eighth  Week.— The  rudiments  of  all  the 
milk  teeth  have  entered  the  stage  of  ossification  in  this  month. 


CHARACTERISTICS  OF  VARIOUS  ORGANS 


03 


Fig.  49 


Fig.  50 
Figs.  49  and  50. — Roentgenogram  Fig.  49  and  diagram  Fig.  50  of  fetus  at  twenty- 
nine  to  thirty-two  weeks,  one-fourth  actual  size. 


Fig.  51 


Fig.  52 
Figs.  51  and  52.— Roentgenogram  Fig.  51  and  diagram  Fig.  52  of  fetus  at  thirty- 
three  to  thirty-six  weeks.     Roentgenogram  one-fourth  actual  size.     Diagram  some- 
what less. 


96  PHYSIOLOGY 

The  development  of  the  transverse  processes  of  the  vertebra? 
progresses  down  to  the  last  lumbar  vertebra.  At  the  end  of  this 
period  a  center  of  ossification  may  develop  in  the  lateral  masses 
of  the  first  and  of  the  second  sacral  vertebrae.  The  body  of  the 
fifth  and  the  arches  of  the  fourth  sacral  vertebra?  become  ossified 
at  this  time,  rarely  earlier. 

A  center  of  ossification  develops  in  the  astragalus. 

In  the  horizontal  ramus  of  the  pubic  bone  the  center  may  develop 
as  late  as  in  this  period. 

Twenty-ninth  to  Thirty-second  Week.— The  greater  cornua  of 
the  hyoid  bone  usually  become  visible,  appearing  as  cone-shaped 
processes  directed  obliquely  upward  at  the  level  of  the  second 
cervical  vertebra. 

The  lateral  masses  of  the  first  and  second  sacral  vertebrae  ossify 
usually  at  this  time. 

In  the  sternum  three  or  more  large  centers  of  ossification  are 
visible. 

The  middle  phalanx  of  the  fourth  toe  frequently  begins  its 
ossification  during  the  period. 

Thirty-third  to  Thirty-sixth  Week.—  This  period  is  the  earliest 
time  at  which  the  first  epiphyseal  center  may  appear,  that  of  the 
distal  epiphysis  of  the  femur.  Usually,  however,  this  center 
appears  later,  at  about  the  time  of  birth. 

The  costal  process  of  the  sixth  and  of  the  fifth  cervical  vertebra? 
begin  their  ossification. 

Thirty-seventh  to  Fortieth  Week.— The  middle  turbinates  ossify  at 
the  end  of  the  fetal  period  and  shortly  before  birth  the  rudiments 
of  the  first  permanent  molar  teeth  begin  to  ossify. 

The  costal  process  begins  to  ossify  in  the  fourth,  the  third  and 
the  second  cervical  vertebra?;  the  first  coccygeal  vertebra  usually 
ossifies  during  the  last  weeks  before  birth  and  vertical  arrangement 
of  trabecular  becomes  visible  in  the  bodies  of  the  vertebra?. 

A  center  of  ossification  appears  in  the  proximal  epiphysis  of  the 
tibia  just  before  birth  in  a  majority  of  cases,  and  ossification  in  the 
cuboid  frequently  starts  before  birth,  usually  by  several  centers, 
although  in  some  cases  it  may  not  be  visible  even  in  the  new  born. 

The  Neiv  Born.— A  center  of  ossification  in  the  distal  epiphysis 
of  the  femur  is  so  frequent  in  the  new  born  that  Lambertz  calls 
it  a  sign  of  maturity.  This  is  frequently  the  only  epiphyseal 
center  present  in  the  new  born.  Poirier1  gives  a  summary  of  the 
literature  on  the  time  of  the  appearance  of  the  epiphysis  at  the 
distal  end  of  the  femur.  Schwegel  found  it  to  appear  between 
birth  and  the  third  year.     Casper  in  the  ninth  fetal  month,     Hart- 

1  Traite  d'anatomie,  1,  227, 


CHARACTERISTICS  OF  VARIOUS  ORGANS 


97 


maun  found  it  lacking  in  12  per  cent  of  cases  at  birth  and  in  7  per 
cent  of  cases  present  as  early  as  the  eighth  fetal  month. 


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98  PHYSIOLOGY 

The  four  parts  of  the  occipital  bone  (basilar,  two  lateral  and 
the  squamous)  are  separated  from  each  other  by  thin  layers  of 
cartilage.  The  mastoid  portion  of  the  temporal  bone  is  not  ossified 
in  its  entire  extent,  a  serrated  line  marking  the  boundary  between 
bony  and  cartilaginous  portions  of  the  mastoid  part.  The  lateral 
halves  of  the  frontal  bone  are  separated.  The  body  of  the  hyoid 
bone  is  usually  ossified.  Both  halves  of  the  mandible,  as  a  rule, 
are  united  by  connective  tissue. 

The  vertebrae  are  ossified  in  all  their  essential  parts,  including 
transverse  and  articular  processes  of  the  arches,  but  the  centers  of 
ossification  are  separated  from  each  other  by  cartilage.  The  first 
coccygeal  vertebra  is  usually  ossified  by  this  time. 

In  some  cases  the  proximal  epiphysis  of  the  humerus  is  ossi- 
fied. In  the  hand  all  bones  are  ossified  except  the  carpus,  in 
which  centers  of  ossification  in  os  magnum  and  unciform  may  be 
seen  only  very  rarely. 

At  birth  the  ossified  portion  of  the  os  pubis  surrounds  usually  a 
portion  of  the  anterior  boundary  of  the  obturator  foramen,  but 
the  region  of  the  symphysis  and  upper  margin  of  the  horizontal 
ramus  of  os  pubis  remain  cartilaginous.  The  following  portions  of 
the  innominate  bone  are  not  ossified  in  the  new  born:  The  crest 
of  the  ilium  with  superior  spines,  acetabulum,  spine  of  ischium  and 
ascending  ramus  of  ischium. 

The  middle  phalanx  of  the  fourth  toe  is  frequently,  that  of  the 
fifth  toe  always,  cartilaginous  in  the  new  born;  in  the  fourth  toe, 
however,  the  middle  phalanx  may  start  in  its  ossification  in  the 
eighth  fetal  month.  The  following  portions  of  the  leg  are  usually 
not  ossified  in  the  new  born:  Proximal  epiphysis  of  tibia  and  of 
the  fibula,  epiphyses  of  metatarsal  bones  and  of  phalanges,  the 
cuboid  and  the  three  cuneiform  bones. 

Other  Methods  of  Studying  Osseous  Development  Compared.— We 
have  compared  the  process  of  ossification,  as  observed  in  the 
roentgenograms  of  the  fetuses  studied  with  the  roentgenographic 
studies  of  Alexander,1  Bade,2  Hasselwander3  and  Lambertz,  and 
found  that  the  time  of  appearance  of  centers  of  ossification  pretty 
well  agrees,  in  general,  there  being  minor  differences  only. 

Compared  with  the  studies  of  Mall,  who  used  transparent  speci- 
mens of  embryos  and  fetuses  for  observing  the  appearance  of 
centers  of  ossification,  we  find  that  by  the  use  of  these  specimens 
he  was  able  to  demonstrate  the  minute  centers  of  ossification  gen- 

1  The  Development  of  the  Osseous  Vertebral  Column,  Fortschr.  a.  d.  Geb.  d. 
Rontgenstrahlen,  Suppl.  13. 

2  Short  Description  of  Ten  Roentgenologically  Examined  Fetuses,  Centralbl.  f. 
Gynak.,  1899,  p.  1031. 

3  Studies  of  Ossification  of  the  Skeleton  of  the  Human  Foot,  Ztschr.  f.  Morphol.  u, 
Anthropol.,  1903,  5,  438, 


CHARACTERISTICS  OF  VARIOUS  ORGANS  99 

erally  about  one  week  earlier  than  they  are  demonstrable  by  roent- 
genograms. This  observation  also  agrees  with  text-books  of 
anatomy  (Rauber-Kopsch,  Gray1)  which  have  been  consulted  for 
this  purpose,  and  it  is  found  that  they  place  the  time  of  appearance 
of  various  centers  about  one  week  ahead  of  the  time  at  which  the 
centers  cast  shadows  large  enough  to  be  visible  in  roentgenograms. 
By  courtesy  of  Dr.  Roy  Lee  Moodie,  of  the  Department  of 
Anatomy  of  the  University  of  Illinois,  we  obtained  transparent 
specimens  of  a  pair  of  twins  from  his  embryologic  collection  and 
made  roentgenograms  of  them.  By  studying  these  roentgenograms 
and  specimens  (Fig.  36)  we  found  the  following  differences: 

Roentgenograms  Transparent  specimens 

Basal  phalanges  of  fingers  3d 2d,  3d,  4th 

Terminal  phalanges  of  toes        .      1st,  2d,  3d     .      .      .      1st,  2d,  3d,  4th 
Bodies  of  vertebrae    ....      9  lower  dorsal     .      .      9  to  10  lower  dorsal,  respec- 

tively 
All  lumbar    .      .      .     All  lumbar 
1st  sacral       .      .      .      1st,  2d  sacral 
Bodies  of  vertebrae    ....      Upper  3  lumbar        .      Upper    3     to    all    lumbar, 

respectively 

Thus  the  transparent  specimens  show  in  the  tenth  week  centers 
that  become  visible  in  the  roentgenogram  only  in  the  eleventh  to 
twelfth  week. 

Variations  in  Osseous  Development.— There  are,  as  might  be 
expected,  some  variations  in  the  normal  process  of  ossification, 
and  it  is  also  influenced  by  pathological  conditions  of  the  mother 
and  of  the  fetus  (for  example,  syphilis,  rickets,  osteogenesis  imper- 
fecta, etc.).  In  general,  these  pathological  processes  may  well  be 
diagnosed  in  the  roentgenograms  so  that  an  error  may  easily  be 
prevented.  In  some  portions  of  the  skeleton  the  ossification  is 
less  regular  than  in  others,  and  as  a  general  rule  the  more  caudad 
the  portions  of  the  skeleton  are,  the  more  they  are  subject  t<> 
variations  in  the  process  of  ossification;  and  the  centers  which 
develop  at  a  later  period  of  fetal  life  are  also  more  variable.  Thus, 
there  are  considerable  variations  in  the  time  of  appearance  of 
centers  of  ossification  in  the  sacral  vertebra1.  The  foot,  as  a 
general  rule,  is  unreliable  as  an  indicator  of  the  age  of  the  fetus. 
The  ossification  of  the  sternum  is  also  irregular  in  the  time  of 
appearance,  size  and  arrangement  of  the  centers  of  ossification. 
The  twelfth  rib  is  also  very  irregular,  and  we  found  it  absent  in 
roentgenograms  of  the  fetus  from  the  thirteenth  to  sixteenth  week, 
and  also  in  some  other  older  ones,  although,  as  a  rule,  the  twelfth 
rib  appears  in  the  tenth  or  in  the  eleventh  week.     Some  of  the 

1  Anatomy,  Descriptive  and  Applied,  Ed.   18,  Lea.  A:   Febiger,  Philadelphia  ami 
New  York,  1910, 


100  PHYSIOLOGY 

centers,  although  demonstrable  by  careful  examination,  are  so 
small  as  to  be  easily  overlooked,  and  this  may  lead  to  an  error. 
For  this  reason  it  is  necessary  to  know  what  centers  we  may  expect 
at  that  particular  age  of  the  fetus,  and  we  should  look  for  them  in 
good  light  with  a  magnifying  glass. 

Bade  has  examined  roentgenograms  of  twin  fetuses,  one  of  which 
was  5.8  cm.  long,  weighing  8  gm.,  and  the  other  6.3  cm.  long, 
weighing  11  gm.  The  only  difference  in  the  stage  of  ossification 
was  that  the  larger  fetus  showed  two  more  centers  in  the  arches 
of  the  vertebrae  and  two  additional  centers  in  terminal  phalanges 
of  the  fingers. 

In  the  twins  from  Dr.  Moodie's  collection,  which  we  have  studied, 
the  only  differences  in  the  stage  of  ossification  are  in  the  axial 
skeleton,  one  fetus  showing  centers  for  seventeen  bodies  and 
twenty-four  arches  on  each  side  and  the  other  only  fifteen  bodies 
and  twenty-two  arches  on  each  side. 

The  process  of  ossification  is  more  constant  for  a  particular  age 
than  the  length  of  the  fetus.  Mall,1  in  his  article  on  ossification 
in  embryos  up  to  one  hundred  days  old,  concludes  that  "  the  remark- 
able regularity  of  the  appearance  of  the  bones  makes  of  them  the 
best  index  of  the  size  and  of  the  age  of  embryo  we  now  possess." 

Limitations  of  Accuracy.  — In  the  first  half  of  pregnancy  the  esti- 
mation of  the  age  of  the  fetus  may  be  made  with  greater  accuracy 
because  many  more  new  centers  appear  in  the  first  months,  and 
also  because  the  time  of  appearance  of  the  earlier  centers  is  more 
constant.  In  later  months  most  centers  in  the  lower  part  of  the 
skeleton  are  available  for  study,  although  these  are  less  constant 
in  the  time  of  their  appearance.  We  have  intentionally  made  our 
groupings  broad  enough  to  cover  minor  errors  in  diagnosis,  but  more 
careful  subsequent  studies  may  refine  the  diagnosis  to  such  a  degree 
that  determination  of  age  will  be  possible  within  the  period  of  one 
week  in  the  first  half  of  the  pregnancy,  and  within  two  weeks  in  the 
second  half  of  the  pregnancy. 

Different  Values  of  the  Different  Portions  of  the  Body.— In  the  very 
early  period  (second  month)  the  stage  of  ossification  of  clavicle 
and  mandible  is  of  chief  importance,  and  on  the  basis  of  presence 
or  absence  of  these  centers  determination  of  the  age  is  made. 
Both  roentgenograms  and  transparent  specimens  show  that  the 
time  of  appearance  of  these  centers  is  almost  constant,  which 
makes  them  of  cardinal  value  in  diagnosis. 

Next  in  importance  are  the  centers  of  the  upper  extremity,  and 
especially  of  the  hand  (metacarpals  and  phalanges)  which  are  very 
regular,  not  only  in  the  time  of  their  appearance,  but  also  in  their 

1  On  Ossification  Centers  in  Human  Embryos  Less  Than  One  Hundred  Days  Old, 
Am.  Jour.  Anat.,  1906,  5,  433- 


CHARACTERISTICS  OF  VA  RIO  US  ORG,  1  MS  101 

sequence.  The  ossification  of  the  diaphysis  of  the  long  bones  of 
the  arms  extends  from  the  eighth  to  the  sixteenth  week,  and  (luring 
this  period  the  determination  of  the  age  may  frequently  he  made 
from  a  good  roentgenogram  of  the  hand  alone. 

The  progress  of  ossification  of  the  head  is  also  of  considerable 
diagnostic  importance,  but  the  centers  in  many  bones  of  the  head 
are  very  difficult  of  demonstration.  Those,  however,  that  can 
he  well  demonstrated  are  of  much  value  in  the  determination 
of  the  age.  This  is  especially  true  of  the  occipital  bone,  superior 
maxilla,  tympanic  ring,  nasal  bone  and  hyoid  bone. 

The  axial  skeleton  (the  vertebral  column)  is  less  reliable  than 
the  foregoing  named  portions  of  the  skeleton,  and  especially  its 
lower  portion  is  of  little  value  in  diagnosis  of  age.  It  is  not  the 
absolute  number  of  arches  or  of  the  bodies  ossified  which  decides 
the  diagnosis  as  to  the  age  of  the  fetus,  but  more  the  region  involved 
and  the  extent  of  the  development  in  the  particular  region  of  the 
vertebral  column  (cervical,  dorsal,  lumbar,  sacral).  On  the  other 
hand,  however,  the  facts  that  the  process  of  ossification  of  the 
vertebral  column  extends  from  the  ninth  week  throughout  the  life 
of  the  fetus,  and  all  its  centers,  as  a  rule,  are  well  demonstrable, 
make  it  of  special  value  for  at  least  approximate  determination, 
although  it  must  not  be  forgotten  that  occasionally  the  process 
of  ossification  may  be  delayed  in  the  vertebral  column,  while  it  is 
normal  and  regular  in  other  portions  of  the  body. 

The  sternum  is  unreliable  as  an  index  of  age  and  its  centers  are 
frequently  difficult  to  demonstrate.  The  ribs  are  fairly  constant, 
except  the  twelfth  pair,  which,  as  previously  mentioned,  may  not 
show  at  all  in  roentgenograms  of  comparatively  old  fetuses. 

While  the  ossifications  of  the  long  bones  of  the  legs  are  pretty 
regular,  since  they  appear  at  an  early  period,  ossification  in  the 
foot  is  very  irregular  and  the  stage  of  ossification  of  the  foot  is 
of  little  value  in  the  determination  of  the  age  of  the  fetus.  The 
osseous  development  of  the  foot  extends  from  the  ninth  week 
to  the  end  of  the  fetal  period  (not  being,  however,  completed  even 
at  this  time)  and  during  this  time  there  are  very  marked  variations, 
especially  in  the  centers  which  appear  late  in  the  fetal  period. 

From  the  above  it  may  be  seen  that,  as  a  general  rule,  the  earlier 
a  center  appears  the  more  regular  it  is,  and  since  the  process  of 
ossification  starts  in  the  cephalic  region  and  spreads  caudally,  it  is 
also  true  that  the  more  caudad  a  skeletal  segment  is  situated  the 
more  it  is  subject  to  variations  and  irregularities. 

Advantages  of  the  Roentgenographic  Method.— The  peculiar  advan- 
tage of  the  roentgenographic  method  for  determining  the  age  of 
the  fetus  lies  in  the  fact  that  while  in  the  determination  of  age 
according  to  the  length  we  base  our  final  conclusions  usually  on 


102  PHYSIOLOGY 

one,  rarely  on  two  or  three  measurements  expressing  different 
lengths  of  the  fetus,  in  the  roentgenographic  method  many  centers 
of  ossification  are  the  factors  taken  into  consideration  before 
arriving  at  a  final  conclusion;  and  they  act  as  check  on  each  other 
and  quite  frequently  the  roentgenograms  alone  give  us  information 
as  to  whether  the  fetus  is  normal  or  not,  a  point  which  seldom  may 
be  determined  from  measurements  alone. 

Technic. — In  studying  the  roentgenograms  it  is  well  to  use  a 
reading  glass  of  about  four  inches  in  diameter,  since  some  centers 
of  ossification  may  be  so  small  as  to  be  very  easily  overlooked  when 
sought  for  with  the  naked  eye. 

If  only  one  exposure  of  the  fetus  is  made  then  the  best  position 
to  show  as  many  ossification  centers  as  possible  is  as  follows:  The 
back  lying  flat  on  the  plate,  head  turned  completely  to  one  side  so 
that  the  side  of  the  head  lies  on  the  plate  and  lateral  exposure  is 
obtained.  (It  should  be  remembered  in  the  study  of  the  skull  that 
both  halves  of  the  skull  are  usually  visible.)  Arms  and  fingers 
should  be  extended  and  fingers  spread  as  far  as  possible  from  one 
another.  One  hand  should  be  pronated  and  the  other  supinated, 
the  lateral  exposure,  which  is  often  of  so  much  value  in  roentgeno- 
grams taken  for  the  purpose  of  surgical  diagnosis,  not  being  of 
much  value,  since  in  this  position  shadows  of  phalanges  of  fingers 
and  of  metacarpals  are  superimposed  and  cannot  be  well  differen- 
tiated. The  legs  should  also  be  extended  and  feet  put  into  such  a 
position  that  all  metatarsals  and  phalanges  are  shown. 


CHAPTER  IV. 
PATHOLOGICAL  FINDINGS  IN  PREMATURES. 

Vert  little  careful  work  has  been  done  with  reference  to  the 
pathological  changes  in  the  premature  infant.  The  discussion 
which  follows  is  a  summary,  largely  taken  from  the  recent  excellent 
work  of  Arvo  Ylppo.1 

Premature  infants  must  be  classified  into  two  groups:  Those 
that  are  born  "weaklings"  owing  to  congenital  deformities  or 
malformations,  congenital  diseases,  especially  lues,  and  the  con- 
genital weaklings  born  of  nephritic,  eclamptic  or  tuberculous 
mothers,  or  those  suffering  from  chronic  toxemia.  In  the  second 
group  are  those  fully  developed  and  normal  for  their  fetal  age. 

One  is  often  amazed  at  the  life  energy  of  these  prematures,  in 
view  of  the  high  grade  pathological  changes  in  the  various  organs, 
especially  the  hemorrhages  into  the  brain  and  spinal  cord. 

Premature  birth  should  be  considered  a  traumatic  process,  in 
which  the  characteristic  pathological  processes  are  most  frequently 
noted  in  three  groups  of  organs,  for  which  there  appears  to  be  a 
predilection : 

1.  The  skull  with  the  brain  and  its  membranes,  inclusive  of  the 
spinal  cord. 

2.  The  lungs. 

3.  The  gastro-intestinal  canal. 

Intracranial  hemorrhages  are  especially  important.  Ylppo 
believes  that  they  are  responsible  for  30  per  cent  of  the  deaths  of 
prematures  in  the  early  days  of  life.  In  the  skull  there  are  sub- 
arachnoidal or  intrapial  hemorrhages,  while  in  the  spinal  column 
they  are  extradural. 

The  so-termed  subdural  hemorrhages  and  those  from  tears  of  the 
tentorium,  which  are  present  in  full-term  infants,  are  only  excep- 
tionally seen  in  prematures. 

Ventricular  hemorrhages  are  frequently  found  in  prematures,  but 
hemorrhage  into  the  brain  substance  proper  is  quite  rare.  High- 
grade  edema  of  the  pia  is,  as  a  rule,  also  present  along  with  these 
intracranial  hemorrhages.  Bacteria  easily  settle  in  the  injured 
brain  membranes  and  meningitic  processes  are  not  uncommon. 

1  Arvo  Ylppo,  Ztschr.  f.  Kindeih.,  xx,  212,  1919. 


104  PATHOLOGICAL  FINDINGS  IN  PREMATURES 

In  the  later  life  of  the  premature  the  appearance  of  spastic 
states  (Little)  and  of  disturbances  in  intelligence  are  often  seen 
and  are  explained  as  a  rule,  undoubtedly,  as  a  consequence  of  old 
hemorrhages  into  the  brain  and  spinal  cord. 

The  condition  spoken  of  in  the  literature  as  hydrocephalus  of 
the  premature,  has,  as  a  rule,  nothing  to  do  with  hydrocephalus. 
The  brain  represents  one-fourth  of  the  body  weight  and  appears 
normal  macroscopically  and  developmentally.  Ylppo  suggests  the 
term  "megacephalus."  This  megacephalus  is  due  to  the  fact  that 
the  brain  develops  at  practically  the  normal  rate,  while  the  growth 
of  the  body  is  retarded. 

Hemorrhages  into  the  lungs  appear  not  only  under  the  pleura, 
but  are  scattered  through  the  entire  parenchyma.  The  alveolar 
septums  are  thickened  because  of  the  extravasations  of  blood. 
The  normal  circulation  in  the  lung  is  hindered  and  in  the  extra- 
uterine life  there  appears  a  stasis,  which  hinders  the  taking  up  of 
air  and  predisposes  secondarily  to  atelectasis.  Following  stasis 
and  bacterial  changes,  there  may  appear  in  the  lungs  of  prematures 
a  high  grade,  almost  total,  inhibition  of  the  circulation  of  the  blood. 

Inflammatory  changes  in  the  lungs  or  bronchi  appear  infrequently 
and  atypically  in  the  first  days  of  life.  Bronchopneumonia,  after 
the  second  week  of  life,  begins  to  play  an  important  part  in  causing 
death. 

Epicardial  hemorrhages  are  of  common  occurrence.  They  appear 
just  as  do  the  subpleural  hemorrhages  and  those  in  all  the  other 
organs. 

Subcapsular  liver  hemorrhages  are  on  a  par  with  other  sub- 
serous hemorrhages.  They  are  important  only  insofar  as  they 
may  be  extensive,  and  with  rupture  of  the  capsule  may  result 
in  hemorrhage  into  the  peritoneal  cavity  with  death. 

Hemorrhages  into  the  kidney  are  frequent.  They  have  two  pre- 
dilections: In  the  interstices  of  the  apices  of  the  pyramids,  or  in 
the  neighborhood  of  the  venae  et  arteriae  arciformes.  Hemor- 
rhages into  the  Malpighian  bodies  and  cortex  are  rare.  Infarcts 
appear  in  the  same  sites  as  the  hemorrhages. 

The  hemorrhages  of  the  digestive  tract  are  next  in  importance 
to  those  of  the  brain.  In  small  prematures,  dying  shortly  after 
birth,  one  often  finds  hemorrhages  scattered  through  the  entire  tract. 
The  areas  of  predilection  are:  The  lower  portion  of  the  esophagus, 
the  cardia  and  fundus  of  the  stomach,  the  mucous  membrane 
folds  in  the  corpus  ventriculi,  the  duodenal  margin  of  the  pylorus, 
and  the  entire  duodenal  mucosa.  In  the  deeper  portions  of  the 
intestines,  hemorrhages  occur  infrequently  about  the  ileo-cecal  valve 
and  in  the  mucosa  of  the  large  bowel.  These  hemorrhages  appear 
chiefly  under  the  epithelial  cells  in  the  tunica  propria.     Blood  often 


PATHOLOGICAL  FINDINGS  IN  PREMATURES  105 

appears  in  the  bowel  lumen  after  rupture  of  the  mucosa.  These 
hemorrhages  in  extra-uterine  life  arc  important  only  insofar  as 
they  predispose  to  infection,  which  readily  occurs.  As  a  result, 
within  one  and  a  half  days  prematures  may  show  a  marked  mucous 
membrane  necrosis  and  peritonitis. 

Inflammatory  processes  within  the  digestive  tract,  especially  in 
the  esophagus  and  duodenal  mucosa  are  also  common.  From  the 
inflamed  intestinal  mucosa,  bacteria  easily  invade  the  blood,  with  a 
following  general  sepsis. 

The  mucosa  of  the  stomach  is  frequently  involved  in  the  septic 
processes  of  the  prematurely  born,  especially  in  their  early  days 
of  life.  Involvement  of  the  stomach  is  often  followed  by  peritonitis 
and  by  Bacillus  coli  septicemia. 

The  histopathological  inflammatory  processes,  due  to  bacteria, 
appear  atypically  in  prematures.  This  is  associated  with  a  very 
ineffective  exudation  of  fibrin  and  scanty  mobilization  of  leuco- 
cytes. Because  of  these  factors  general  sepsis  in  all  infections 
appears  easily. 

The  hemorrhages  are  due  to  diapedesis,  rhexis,  or  both,  and  vary 
with  the  intensity  and  duration  of  stasis  and  the  grade  of  the  infec- 
tions—toxic damage  to  the  capillary  walls. 

The  preceding  summary  of  the  pathological  changes  in  the 
premature  has  been  concerned  chiefly  with  the  question  of  hemor- 
rhage. (Specific  pathology  will  be  discussed  later  under  the 
"Diseases  of  the  Prematurely  Born.") 


PART  II. 
NURSING  AND  FEEDING  CARE. 


CHAPTER  V. 
MATERNAL  NURSING. 

NURSING  AXIOMS. 

The  following  may  be  laid  down  as  nursing  axioms: 

A  diet  similar  to  what  the  mother  was  accustomed  to,  with 
moderate  limitations,  may  be  taken. 

There  should  be  one  bowel  evacuation  daily. 

From  three  to  four  hours  daily  should  be  spent  in  the  open  air 
in  exercise  which  does  not  fatigue 

At  least  eight  hours  out  of  every  twenty-four  should  be  given 
to  sleep. 

There  should  be  absolute  regularity  in  nursing  and  expression. 

There  should  be  no  worry  and  no  excitement. 

HYGIENE  OF  THE  MOTHER. 

The  Diet  of  the  Mother.— A  plain,  more  or  less  restricted  diet  is 
desirable.  This  must  be  enforced  in  the  management  of  the  wet- 
nurse,  but  to  a  less  degree  with  the  mother. 

Nursing  is  a  perfectly  normal  function,  and  a  woman  should  be 
permitted  to  carry  it  out  along  the  natural  lines.  Inasmuch  as 
there  are  two  lives  to  be  provided  for  instead  of  one,  more  food, 
particularly  of  a  liquid  character,  may  be  taken  than  the  mother 
may  be  accustomed  to.  It  is  our  custom  to  advise  that  milk  be 
given  freely.  A  glass  of  milk  may  be  taken  in  the  middle  of  the 
afternoon,  and  8  ounces  of  milk  with  8  ounces  of  oatmeal  or  corn- 
meal  gruel  at  bedtime,  if  it  does  not  disagree  with  the  mother.  Our 
only  evidence  that  a  food  is  disagreeing  is  the  condition  of  the 
digestion.  When  any  article  of  food  disagrees  with  the  mother, 
or  if  she  is  convinced  that  it  disagrees,  whether  or  not  such  be 
really  the  case,  the  food  should  be  discontinued.     In  a  general 


108  MATERNAL  NURSING 

way,  milk  (1  quart  daily),  eggs,  meat,  fish,  poultry,  cereals,  fresh 
vegetables  and  fruits  constitute  a  basis  for  selection. 

For  more  detailed  suggestions  see  page  122. 

The  Bowel  Function.— A  very  important  and  often  neglected 
matter  in  relation  to  nursing  is  the  condition  of  the  bowels. 
There  must  be  one  free  evacuation  daily.  For  the  treatment 
of  constipation  in  nursing  women  we  have  used  different  methods 
in  many  cases.  The  dietetic  treatment  by  increasing  the  whole 
cereals,  rough  breads  and  cooked  vegetables  with  plenty  of  recrea- 
tion and  exercise  promise  most.  Manipulation  of  the  diet  should 
not  be  such  as  to  interfere  with  the  milk  production  Three  other 
methods  are  open  to  use;  massage,  local  measures  and  drugs. 
Massage  is  available  in  comparatively  few  cases.  Local  measures 
consist  in  the  use  of  enemas  and  suppositories.  Every  nursing 
woman  under  our  care  is  instructed  to  use  an  enema  at  bedtime  if 
evacuation  of  the  bowels  has  not  taken  place  during  the  previous 
twenty-four  hours.  For  a  laxative  in  such  cases,  and  in  many 
others,  a  capsule  of  the  following  composition  has  served  well: 

1$ — Extracti  nucis  vomicae 0.015  gm.  (j  gr.) 

Extracti  cascarae  sagradae        . 0.325  gm  (v  gr.) 

Sig. — To  be  taken  at  bedtime. 

The  amount  of  the  cascara  sagrada  may  be  varied  as  the  case 
may  require.  In  not  a  few  instances  we  have  found  it  necessary 
to  give  two  capsules  a  day  in  order  to  produce  the  desired  result. 
Neither  the  nux  vomica  nor  the  cascara  appears  to  have  any 
appreciable  effect  on  the  child. 

Air  and  Exercise.— Outdoor  life  and  exercise  are  not  only  as 
desirable  here  as  they  are  under  all  other  conditions,  but  to  the 
nursing  woman,  with  her  added  responsibility,  they  are  doubly 
valuable.  In  order  to  get  the  best  results  exercise  or  work  should 
be  so  adjusted  as  not  to  reach  the  point  of  fatigue.  The  mother 
whose  nights  are  disturbed  should  be  given  the  benefit  of  a  midday 
rest  of  an  hour  or  two.  It  should  be  our  duty,  however,  to  explain 
to  the  mother  and  to  other  members  of  the  family  that  an  import- 
ant element  in  satisfactory  nursing  is  a  tranquil  mind. 

Care  of  the  Breasts.— A  well-established  routine  should  be  insti- 
tuted for  the  care  of  the  breasts.  To  facilitate  this  a  readily 
accessible  tray  with  the  necessary  utensils  should  be  provided. 
This  should  contain  a  glass-stoppered  bottle  with  a  saturated  solu- 
tion of  boric  acid,  a  jar  of  cotton  pledgets  on  toothpicks,  to  be  used 
as  applicators  for  the  boric  acid,  a  graduated  glass  or  beaker.  The 
nipples  should  be  thoroughly  washed  before  and  after  nursing  with 
a  saturated  solution  of  boric  acid  poured  fresh  from  the  bottle  for 
each  cleansing,  and  the  surplus  thrown  away.  The  boric  acid 
should  be  applied  with  the  cotton  pledgets.     The  fingers  should 


CONDITIONS  INFLUENCING  THE  BREAST  MILK       109 

not  come  in  contact  with  the  nipples  if  the  child  is  to  nurse  directly 
at  the  breast.  If  the  nipples  are  tender  they  should  be  anointed 
with  a  sterile  mixture  of  5  per  cent  tincture  of  benzoin  in  liquid 
vaseline. 

All  utensils,  including  the  breast-pump,  if  one  is  in  use,  should 
be  sterilized  by  boiling.  In  case  of  the  breast-pump  the  rubber 
bulb  may  be  removed  for  this  purpose.  Where  the  milk  is  to  be 
expressed  the  hands  must  be  thoroughly  disinfected  by  washing 
with  soap  and  water  and  rinsing  before  manipulation  of  the  breasts. 
Under  all  conditions  soap  and  water  should  be  freely  accessible, 
and  their  use  required  before  handling  the  breast  of  the  mother. 

CONDITIONS  INFLUENCING  THE  BREAST  MILK. 

Secretion.— Spontaneous  failure  of  lactation  is  extremely  rare 
and  probably  always  occurs  in  consequence  of  an  incomplete 
emptying  and  an  insufficient  stimulation  of  the  breasts.  This  is 
especially  true  in  the  feeding  of  premature  infants,  and  nursing 
must  be  supplemented  by  other  methods  of  emptying  the  breasts, 
such  as  expression,  pumping,  or  the  nursing  of  a  second  infant. 

The  ability  to  restore  the  milk  supply  in  breasts  which  have 
not  been  nursed  for  days  and  even  weeks,  when  proper  stimulation 
is  applied  is  the  best  proof  of  this  assertion. 

When  the  milk  supply  is  temporarily  insufficient  the  necessary 
complemental  feedings  should  be  obtained  from  some  other  source 
and  only  as  a  last  resort  should  mixed  feeding  be  instituted. 

Fissures.— Fissures  offer  serious  difficulties  to  nursing  because  of 
the  severe  pain  and  danger  of  mastitis. 

Relief  of  the  pain  is  frequently  accomplished  by  elevation  of 
the  breasts  by  a  binder.  Among  the  best  local  applications  are 
silver  nitrate  solution  5  per  cent,  followed  by  an  ointment.  (Bal- 
sam of  Peru  1,  castor  oil  30;  or  silver  nitrate  1,  balsam  of  Peru  2 
and  petrolatum  30.) 

The  nipples  must  be  thoroughly  cleansed  before  each  nursing. 

Simple  Engorgement.— The  first  essential  to  relief  is  the  restriction 
of  fluids  by  mouth  and  the  administration  of  laxatives.  In  our 
experience  compound  jalap  powder  in  teaspoonful  doses  once  or 
twice  daily  is  best.  Saline  laxatives  are  effective  but  more  likely 
to  pass  into  the  milk.  Citrate  of  magnesia  is  least  likely  to  do  this. 
The  breasts  are  tightly  bandaged  and  an  ice-bag  is  applied  to  each, 
external  to  the  bandage.  If  this  does  not  relieve  the  breasts  mas- 
sage and  expression  should  be  practised  and  the  bandage  and 
ice-bags  reapplied. 

If  the  cold  applications  produce  discomfort  as  they  occasion- 
ally do,  hot  boric  dressings,  protected  by  oil  silk  may  be  used,  a 


110  MATERNAL  NURSING 

compression  bandage  being  applied  external  to  the  dressings. 
These  should  be  repeated  at  hourly  intervals. 

The  infant  should  be  put  to  breast  regularly  at  four-hour  inter- 
vals if  able  to  take  them.  The  wet-nurse's  baby  may  be  used 
for  this  purpose  if  at  hand. 

Mastitis.— Ice-bags  are  best  applied  early.  Later,  warm  moist 
applications  are  more  useful.  When  incision  is  necessary  it  should 
be  radial  and  must  not  enter  the  mammilla.  This  should  be  per- 
formed as  soon  as  pus  is  localized  and  is  to  be  followed  by  expres- 
sion through  the  incision.  In  order  to  prevent  further  congestion 
of  the  breasts  gentle  expression  should  be  practised  at  regular 
intervals.  This  not  only  relieves  the  congestion,  but,  in  a  very 
large  percentage  of  cases,  it  tends  to  localize  infection  and  a  normal 
secretion  is  retained  after  the  healing  of  the  incision. 

Menstruation.— The  advent  of  this  physiological  function  is 
frequently  attended  by  a  lessened  milk  secretion  which  leads  the 
infant  to  become  fretful  due  to  underfeeding.  Occasionally  men- 
struation is  attended  by  attacks  of  colic  or  indigestion  in  the  infant, 
but,  under  no  circumstances,  should  the  advent  of  menstruation  be 
considered  as  an  indication  for  weaning,  as  all  of  the  symptoms 
disappear  within  two  or  three  days. 

Factors  influencing  the  mental  condition  of  the  mother,  such  as 
anger,  fright,  worry,  shock,  distress,  sorrow,  or  the  witnessing  of 
an  accident  may  affect  the  milk  secretion  sufficiently  to  cause  no 
little  discomfort  to  the  child,  and  oftentimes  the  lessening  of  the 
flow  for  a  day  or  two.  At  times,  especially  when  the  mother  is 
under  the  influence  of  shock  or  grief,  it  may  be  necessary  to  substi- 
tute artificial  feeding  for  a  few  nursings  during  these  periods,  until 
the  mother  has  again  resumed  her  mental  equilibrium,  her  breast 
being  emptied  by  mechanical  means  in  the  meantime. 

Asthenia  and  Anemia  without  a  definite  underlying  organic- 
pathology  must  not  be  considered  sufficient  causes  for  weaning. 
Most  of  such  women  receive  benefit  to  their  own  health,  increasing 
in  weight  and  strength  and  often  overcoming  their  anemia.  This 
is  probably  due  to  the  more  complete  involution  during  the  puer- 
perium  and  stimulation  of  the  glands  of  internal  secretion  and 
blood-making  organs. 

Drugs.  — Alkaloids  of  opium,  hyoscyamus,  belladonna  and  similar 
drugs,  when  given  in  large  quantities  not  infrequently  pass  into 
the  milk,  and  should  therefore  never  be  administered  in  large 
quantities  to  the  nursing  mother.  Belladonna  may  cause  a  decrease 
in  milk  secretion,  and  should  be  administered  with  caution  during 
the  period  of  lactation.  Mercury,  iodides  and  the  newer  salts  of 
arsenic  are  also  secreted  in  the  milk,  and  may  be  used  to  advantage 
when  a  luetic  mother  is  nursing  a  luetic  infant. 


THE  NURSING  PROPER  111 


THE  NURSING  PROPER. 


Regularity  in  Nursing.— The  breast  which  is  emptied  at  definite 
intervals  invariably  functionates  better  than  does  one  which  is 
not,  not  only  as  regards  the  quantity,  but  also  the  quality,  of  the 
milk,  thus  regular  habits  in  breast-feeding  are  as  essential  to  milk 
production  as  to  its  digestion  and  assimilation.  The  baby  should 
be  wakened  to  be  fed. 

The  average  mother  will  supply  the  needs  of  the  individual  meal 
with  one  breast,  and  the  breasts  should  be  alternated  in  successive 
feedings.  Thorough  emptying  of  the  breast  should  be  encouraged 
under  all  circumstances,  as  this  is  our  best  method  for  increasing 
the  milk  supply,  and  the  baby  is  the  best  means  at  hand  by  which 
this  is  accomplished.  This  should  be  encouraged  in  every  instance. 
It  is  most  readily  thwarted  by  allowing  a  lazy  baby  to  partially 
empty  both  breasts.  This  will  soon  lead  to  a  diminished  milk  secre- 
tion. Expression  or  the  nursing  of  a  second  baby  will  usually 
prevent  the  loss  of  milk  supply.  Massage  will  often  be  of  great 
assistance  in  retaining  the  milk  flow.  It  should  be  carefully 
and  gently  applied  at  regular  intervals. 

Sometimes,  however,  it  is  advisable  to  give  both  breasts  at  each 
feeding,  i.  e.,  under  the  following  conditions:  (1)  During  the  first 
few  days  to  stimulate  secretion,  and  a  little  later  to  relieve  the 
congested  breasts;  (2)  to  weak  babies  when  there  is  an  abundance 
of  milk,  and  they  are  not  strong  enough  to  get  the  last  milk  that 
comes  harder;  (3)  to  overfed  babies,  where  it  is  desirable  to  give 
them  only  the  first  and  weakest  milk,  and  to  lessen  the  yield  of 
milk  from  the  breast;  (4)  as  the  milk  supplied  by  one  breast 
fails  to  meet  the  needs  of  the  infant,  both  breasts  should  be  given 
at  each  nursing— the  first  breast  should  be  thoroughly  emptied 
before  allowing  the  baby  to  take  the  second  breast,  and  the  next 
nursing  started  on  the  second  breast  given  in  the  last  feeding. 

When  to  Begin  First  Feedings.— Little  is  to  be  gained  by  placing 
a  premature  infant  to  the  mother's  breast  during  the  first  twenty- 
four  hours  and  as  they  do  not  stand  starvation  the  limited  supply 
of  milk  needed  should  be  obtained  from  some  other  mother.  Water 
should  be  administered  four  or  five  times  during  the  first  twenty- 
four  hours.  When  the  premature  is  unable  to  take  the  breast, 
massage  and  expression  should  be  begun  on  the  second  day  and 
continued  at  first  four,  and  later  six,  times  daily.  When  a  wet- 
nurse's  baby  is  available  it  should  be  left  to  suckle  the  mother's 
breast  at  stated  intervals. 

Number  of  Feedings  in  Twenty-four  Hours.  — During  the  second, 
third  and  fourth  days  the  infant  may  be  placed  at  the  breast  at 
four-  to  six-hour  intervals,  and  if  strong  enough  to  nurse  these  may 


112  MATERNAL  NURSING 

be  increased  so  that  it  will  be  nursed  every  three  or  four  hours. 
If  it  does  not  obtain  sufficient  food  by  this  means  it  may  be  given 
hand  feedings  of  expressed  milk  between  nursings. 

Length  of  Nursing.— As  a  rule,  a  robust  baby  takes  three-fourths 
of  the  milk  obtained  from  a  good  breast  in  the  first  five  minutes 
of  a  twenty-minute  nursing.  Fifteen  to  twenty  minutes  should  be 
the  limit  for  the  nursing  period.  If  a  baby  is  doing  well  on  shorter 
periods  and  seems  satisfied,  let  it  be  its  own  judge  of  the  nursing 
time.  While  premature  infants  may  nurse  well  during  their  first 
three  or  four  days  of  life,  frequently  when  they  become  intensely 
jaundiced  they  develop  a  marked  apathy  and  under  such  circum- 
stances they  must  be  awakened  during  the  nursing  period  to  keep 
them  at  work.  At  such  times  they  must  at  least  be  partially  hand 
fed.     It  may  also  be  necessary  to  feed  them  more  frequently. 

Administration  of  Water.— At  least  one-twentieth  to  one-twelfth  of 
the  body  weight  of  the  infant,  in  the  form  of  inert  fluids,  should  be 
fed  daily  during  the  first  two  days.  A  1  per  cent  milk-sugar  solution 
(boiled)  will  answer.  For  further  fluid  intake  needed  see  Tables  I, 
II  and  III,  pages  181  and  182.  Otherwise  there  will  be  unnecessary 
loss  of  weight  and  perhaps  a  high  degree  of  fever  due  to  inanition. 
A  high  temperature  during  the  first  days  of  life  is  more  commonly 
due  to  "inanition"  than  infection  in  present-day  obstetrics.  The 
best  differential  test  is  administration  of  water  or  sugar  water  at 
regular  intervals.  In  case  of  water  inanition  sufficient  fluid  intake 
results  in  a  rapid  drop  in  the  temperature. 

Nursing  in  Difficult  Cases.— When  the  weight  curve  remains  sta- 
tionary or  the  gain  is  less  than  should  be  expected  the  possibility 
of  underfeeding  as  the  cause  must  not  be  lost  sight  of.  The  esti- 
mation of  the  twenty-four-hour  secretion  of  milk  is  of  first  import- 
ance because  of  the  relationship  between  demand  and  supply. 
The  quantity  taken  by  the  infant  at  each  nursing  should  be  meas- 
ured by  weighing  before  and  after  feeding  at  the  breast,  and  also 
by  measuring  the  amount  of  milk  fed  by  hand.  Conclusions 
should  be  made  only  after  such  estimation  for  a  period  of  at  least 
twenty-four  to  forty-eight  hours.  Expression  of  both  breasts  after 
each  nursing  may  be  of  advantage  to  the  mother  even  though 
the  baby  is  only  nursing  on  one  breast.  Expression  when  thor- 
oughly and  properly  applied  will,  in  itself  maintain  a  full  and 
free  milk  supply  without  placing  an  infant  at  the  breast.  In  some 
instances  this  may  be  continued  for  many  months.  It  may  be 
stated  that  the  small  flat  breast  offers  greater  difficulties  to  proper 
manipulation  than  the  full  conical  breast.  For  details  as  to  the 
method  of  expression  see  page  126. 

The  classes  of  cases  which  are  most  likely  to  necessitate  hand 
feedings  are  those  suffering  from  cleft  palate  and  harelip  and  those 


THE  NURSING  PROPER  113 

in  which  there  is  deformity  of  the  mother's  nipples.  We  have 
recently  had  an  opportunity  to  observe  some  of  the  cases  being 
treated  by  the  Minneapolis  Breast  Feeding  Bureau.  Among  these 
a  very  severe  case  of  harelip  and  cleft  palate,  nine  months  of  age, 
and  a  case  of  congenital  absence  of  nipples  in  the  mother,  whose 
infant  was  five  months  of  age.  Both  of  these  infants  had  been 
fed  exclusively  on  expressed  milk  and  had  attained  the  average 
weight  and  development  of  breast-fed  infants  of  their  respective 
ages. 


CHAPTER  VI. 
WET-NURSING. 

THE  WET-NURSE.     HER  SELECTION  AND  HER  BABY. 

The  Problem.— When  there  is  a  positive  inability  on  the  part 
of  the  mother  to  nurse  her  offspring,  either  through  inadequate 
functioning  on  the  part  of  the  breast  or  systemic  disease,  we  are 
confronted  with  the  problem  of  securing  human  milk  from  another 
source,  as  notwithstanding  the  numerous  isolated  reports  on  suc- 
cessful raising  of  premature  infants  on  artificial  foods,  the  statistics 
of  infants  fed  by  artificial  foods,  when  compared  with  those  of 
infants  fed  on  human  milk  are  so  strikingly  in  favor  of  the  latter 
that  the  obtaining  of  human  milk  must  be  considered  imperative. 

How  Obtained.— In  our  experience,  even  in  a  large  city,  great 
difficulty  has  been  met  in  obtaining  a  regular  supply  of  wet-nurses. 
On  several  occasions  various  charitable  and  hospital  societies  have 
attempted  to  establish  a  wet-nurses'  registry  as  a  clearing  house 
for  the  several  maternity  and  general  hospitals  of  Chicago.  These 
attempts  have  not  been  successful  for  two  reasons:  (1)  Because 
of  the  irregularity  in  the  demand,  and  (2)  because  of  the  lack  of 
cooperation  on  the  part  of  the  various  institutions  caring  for  this 
class  of  cases. 

The  Nationality  of  the  Wet-nurse.— This  is  of  considerable  signifi- 
cance where  the  supply  allows  of  a  selection.  The  phlegmatic 
temperaments  as  seen  in  women  of  Northern  and  Central  Europe 
of  Teutonic  and  Slavic  descent,  offer  the  ideal  material,  while  other 
nationalities,  such  as  Italians,  and  the  Southern  negroes  when 
removed  from  their  home  environment  to  a  Northern  climate  with 
the  consequent  change  in  diet,  secrete  a  milk  poor  in  quality. 
However,  even  the  latter  in  an  emergency  should  not  be  neglected. 

Requirements  of  a  Good  Wet-nurse.  — 1.  She  should  be  in  good 
health,  and,  especially,  free  from  all  contagious  and  infectious 
diseases,  and  also  from  local  diseases  of  any  kind,  such  as  those 
involving  the  nose,  throat,  skin,  etc. 

2.  Her  mammary  glands  should  be  of  such  quality  that  she  can 
secrete  sufficient  milk  of  good  quality,  and  the  nipples  sufficiently 
developed  to  allow  of  nursing,  or  proper  expression  of  the  milk 
(Figs.  54  and  55). 

3.  Whenever  possible  her  age  should  be  not  less  than  eighteen 
and  not  more  than  thirty-five  years. 


THE  WET-NURSE— HER  SELECTION  AND  HER  BABY     115 

4.  The  age  of  her  baby,  as  compared  with  that  of  the  baby  she 
is  to  nurse,  is  a  matter  of  indifference  in  most  instances.     However, 


Fig.  54. — A  good  secreting  spherical  breast  with  well  developed  nipples.  The 
breast  is  composed  largely  of  glandular  tissue.  The  engorged  veins  are  plainly  visible. 
This  young  primipara  acted  as  a  wet-nurse  for  over  eighteen  months.     See  p.  124. 


Fig.  55. — Large,  pendulant  breasts  composed  mainly  of  fat  and  connective  tissue, 

the  type  to  be  avoided  in  the  selection  of  a  wet-nurse. 


the  first  weeks,  or  if  possible  the  first  two  months,  of  lactation  should 
be  avoided,  because  of  the  presence  of  colostrum  and  the  rapidly 


116  WET-NURSING 

changing  quality  of  the  breast  milk,  which  not  infrequently  causes 
serious  gastric  and  intestinal  disturbances  in  very  susceptible 
infants,  as  evidenced  by  vomiting,  colic  and  diarrhea.  Multipar- 
ity  may  be  considered  an  asset,  if  the  nurse  has  demonstrated  her 
ability  to  care  for  and  feed  previous  cases.  A  multipara  is  also 
less  likely  to  be  affected  by  her  new  surroundings,  especially  if 
this  be  a  private  home.  When  the  wet-nurse  has  more  or  less 
direct  charge  of  the  infant,  one  who  has  been  nursing  her  own  or 
other  infants  will  be  likely  to  meet  the  technical  difficulties  in  the 
care  of  her  charge. 

Examination  of  the  Wet-nurse.— The  examination  of  the  wet- 
nurse  should  always  be  made  in  a  systematic  manner  to  insure 
against  overlooking  important  things. 

1.  A  careful  history  should  be  taken  as  to  the  number  of  her 
children,  miscarriages  and  the  presence  of  constitutional  diseases 
in  her  family. 

2.  She  should  be  thoroughly  examined,  all  parts  of  the  body 
being  exposed,  and  the  examination  should  include  the  skin  and 
hairy  parts  of  the  body  for  the  presence  of  skin  lesions  and  para- 
sites, as  well  as  for  old  luetic  scars.  The  organs  of  the  chest  and 
abdomen  should  be  subjected  to  careful  examination. 

3.  The  breasts  should  be  examined. 

4.  The  genitalia,  including  the  cervix  and  the  urethra,  and  in 
all  cases  a  cervical  (and  where  suspicious,  a  urethral)  smear  should 
be  taken  and  examined  for  gonococci.  As  a  single  smear  is  often 
misleading,  in  cases  of  the  slightest  suspicion  where  a  girl  baby  is 
to  be  nursed  the  examination  of  the  cervical  and  urethral  smears 
should  be  repeated. 

5.  An  examination  and  search  should  be  made  for  chronic  infec- 
tions, especially  for  syphilis.  A  Wassermann  test  should  be  made 
in  every  case,  and  reported  upon  before  she  is  allowed  to  supply 
milk,  as  it  is  well  known  that  a  syphilitic  mother  in  a  very  great 
number  of  cases  shows  no  clinical  evidence  of  syphilis.  The  mouth 
and  pharynx,  neck,  anus  and  genitalia,  entire  skin  and  lymphatic 
glands  should  also  be  examined  for  evidence  of  syphilitic  lesions. 

Tuberculosis.— The  lungs,  glands  and  osseous  system  should  be 
examined,  and  a  careful  history  as  to  susceptibility  to  colds  and  to 
recurring  bronchitis  elicited. 

6.  Acute  Infections.— She  should  be  questioned  as  to  exposure  to 
contagious  disease,  and  she  should  be  examined  for  evidence  of 
acute  infections  of  the  nose,  throat  and  ears. 

7.  Her  teeth  should  be  examined  and  defects  and  pyorrhea  cor- 
rected, if  necessary,  at  the  expense  of  the  family. 

8.  The  urine  should  be  examined  (a)  for  evidence  of  nephritis, 
(6)  for  evidence  of  diabetes.     It  should,  however,  be  remembered 


THE  WET-NURSE— 11  EH  SELECTIOh    AND  HER  BABY     117 

that  a  positive  reaction  for  sugar  should  not  lie  overestimated, 
unless  the  sugar  is  proven  to  be  dextrose,  as  very  commonly  in  our 
experience  during  the  early  weeks  of  lactation  a  lactosuria  is  pres- 
ent. The  kind  of  sugar  can  easily  be  determined  by  the  phenyl- 
hydrazine  test,  followed  by  a  microscopical  examination  of  the 
crystals. 

9.  Nervous  and  psychic  disturbances,  such  as  epilepsy,  insanity, 
hysteria,  should,  if  found,  by  all  means  exclude  the  subject. 

10.  Her  child  should  be  examined  for  evidence  of  syphilis. 
Possibly  one  of  the  best  arguments  for  the  non-employment  of  a 
wet-nurse  during  the  first  two  months  of  her  lactation  is  the  possi- 
bility of  a  latent  syphilis.  Where  there  is  the  slightest  doubt,  a 
Wassermann  reaction  should  be  made  on  the  infant.  The  general 
condition  of  the  child  gives  us  the  best  evidence  both  as  to  the 
quantity  and  to  the  quality  of  the  maternal  milk.  Unless  the 
source  of  the  nurse  be  known,  it  is  well  to  be  certain  that  she  is 
nursing  her  own  baby.  In  case  of  its  death  or  its  absence,  every 
effort  should  be  made  to  obtain  its  condition  at  birth  and  its  later 
development. 

So  far  as  possible  she  should  not  be  subjected  to  annoying  ques- 
tioning on  the  part  of  the  family,  which  is  entirely  unnecessary, 
if  she  has  been  properly  examined  by  the  physician.  It  has  been 
our  experience  that  such  unnecessary  questioning  has  led  to  ner- 
vousness, and  not  infrequently  has  caused  her  to  decline  the  position, 
at  a  time  when  she  was  most  needed. 

Her  Place  in  the  Household.— She  should  be  treated  neither  as  a 
guest  nor  as  a  menial,  but  so  far  as  possible  should  be  graded  accord- 
ing to  her  previous  station  in  life.  There  is  grave  danger  of  mental 
depression  on  the  part  of  a  woman,  well-born  and  sensitive, who, 
through  misfortune  or  necessity,  is  forced  to  seek  this  means  of 
employment,  and  also  of  an  exaggerated  estimate  of  self-importance 
on  the  part  of  a  woman  but  little  accustomed  to  the  luxuries  of 
life  upon  her  entrance  into  the  home  of  employment,  particularly 
if  attentions  are  paid  to  her.  As  has  been  previously  stated,  all 
instructions  and  demands  should  be  made  by  the  person  best 
qualified  in  the  individual  case.  A  divided  responsibility  will 
always  lead  to  future  complications. 

Her  quarters  should  be  well  located;  their  ventilation  should 
be  supervised,  and  she  should  be  held  responsible  for  their  general 
cleanliness.  The  wet-nurse's  baby  should  always  be  kept  in  the 
room  with  her,  so  that  she  may  feel  the  full  responsibility  for 
its  health  and  care. 

The  Quantity  of  Milk  to  be  Expected  from  a  Good  Wet-nurse.— The 
quantity  and  quality  of  milk  supplied  must  vary  greatly  with 
the  glandular  development  of  the  individual  wet-nurse,  the  state 


118  WET-NURSING 

of  her  health,  and  the  factors  quoted  elsewhere  which  would  affect 
it  temporarily.  The  amount  and  variety  of  stimulation  applied  to 
the  breasts,  of  which  the  direct  nursing  by  a  full-term  infant  is 
the  most  valuable  (at  least  for  the  purpose  of  stripping  the  breasts), 
must  be  given  due  consideration.  In  view  of  the  many  emergencies 
and  influencing  factors,  no  absolute  standard  for  quantity  and 
quality  can  be  set  for  general  rule.  A  wet-nurse  who  does  not 
secrete  sufficient  milk  during  the  first  few  days  in  her  new  employ- 
ment should  not  be  discharged  until  every  effort  has  been  made  to 
improve  her  milk  production.  Frequently  the  change  in  environ- 
ment is  sufficient  to  reduce  it  temporarily. 

Cost  of  Milk.— The  wet-nurses  in  the  Sarah  Morris  Hospital 
receive  their  board  and  room  and  $10  per  week.  Figuring  the 
former  at  $8  per  week,  this  would  total  a  cost  to  the  institution 
of  $18  per  week  for  each  nurse.  With  an  average  of  30  to  40  ounces 
of  milk  per  nurse  daily,  or  210  to  300  ounces  per  week,  the  average 
cost  will  be  about  6  to  9  cents  per  ounce,  or  approximately  $2  to 
$3  per  quart. 

When  milk  is  dispensed  to  patients  outside  of  the  hospital,  a 
charge  of  15  cents  an  ounce  is  made  for  it,  which  is  a  reasonable 
price  when  all  of  the  contending  factors  are  taken  into  consideration. 

Number  of  Nurses  Needed.  — Each  good  wet-nurse  can  care  for 
the  needs  of  about  two  infants,  depending  upon  their  weight  and 
development,  beside  allowing  the  strippings  for  her  own  child. 

Length  of  Lactation.— No  time  limit  is  placed  upon  the  employ- 
ment of  a  wet-nurse  as  long  as  the  quality  and  quantity  of  her  milk 
is  sustained,  and  she  continues  in  good  health.  One  of  our  nurses 
had  a  lactation  period  of  eighteen  months.  Such  long  periods  of 
lactation,  however,  are  not  to  be  advised. 

The  Wet-nurse's  Baby.— The  presence  of  the  wet-nurse's  baby 
predisposes  to  her  peace  of  mind,  and  wherever  possible,  she  should 
take  it  with  her.  Her  baby's  state  of  health  is  by  all  means  the 
best  indication  as  to  her  ability  as  a  nurse,  and,  with  this,  of  the 
presence  of  constitutional  disease  in  herself.  It  may  be  of  immense 
value,  if  the  baby  is  strong  and  healthy,  to  keep  up  the  flow  of 
of  milk,  in  case  the  baby  to  be  nursed  is  a  weakling.  It  may  also 
be  used  to  estimate  the  functional  capacity  of  a  wet-nurse  by 
nursing  at  regular  intervals,  and  weighing  before  and  after  the 
nursing  for  twenty-four-hour  periods.  If  in  perfect  health  it  may 
be  put  to  the  breast,  after  the  weakling  has  taken  such  milk  as  it 
has  strength  to  draw.  If  this  is  not  practicable  then  the  weakling 
should  be  nursed  alternately  with  the  well  baby  on  each  breast. 
It  is  also  of  immense  value  in  emptying  the  breast  after  the  wet- 
nurse  has  removed  as  much  milk  as  it  is  possible  by  expression  or 
by  the  breast-pump,  if  this  is  the  means  of  drawing  the  milk  for 


THE  HYGIENE  OF  THE  WET-NURSE  119 

the  weakling.  It  is  a  well-known  fact  in  all  institutions  where 
wet-nurses  are  used,  that  the  greater  the  degree  to  which  the 
breasts  are  stimulated  by  suckling  infants,  the  greater  will  he  the 
reward  in  production.  If  the  milk  is  insufficient  for  both  babies, 
partial  or  entire  meals  of  artificial  food  may  be  substituted  for  the 
wet-nurse's  infant. 

At  the  first  sign  of  an  acute  illness  on  the  part  of  the  wet-nurse's 
baby,  it  should  be  separated  entirely  from  the  other  baby,  and 
removed  from  the  breast;  its  illness  should  be  given  the  same 
serious  consideration  as  that  of  the  other  infant,  so  that  the  mother's 
anxiety  may  be  relieved.  It  should  receive  as  much  of  its  mother's 
milk  as  can  be  spared.  This  can  be  expressed  from  the  breasts 
and  fed  from  a  bottle. 

Feeding  of  the  Wet-nurse's  Baby.— When  a  single  infant  is  to  be 
nursed  the  second  baby  is  often  a  necessity  in  the  promotion  of 
the  development  and  stimulation  of  her  breasts.  No  breast  can 
be  developed  to  its  fullest  capacity  with  the  breast-pump  or  hand 
expressions.  It  is  a  well-known  fact  that  the  breasts  will  respond 
in  proportion  to  the  demand  placed  upon  them,  and  in  most 
instances  during  the  first  few  weeks  of  the  premature's  life,  when 
its  demands  are  met  by  from  4  to  1(3  ounces  of  milk,  the  wet-nurse 
can  supply  sufficient  milk  for  both  babies.  When  her  supply 
becomes  insufficient  to  meet  the  demands,  her  baby  can  be  put 
upon  partial  bottle  feedings  of  the  strength  as  indicated  by  its 
age  and  development.  The  progress  of  the  wet-nurse's  baby  has 
great  influence  on  her  peace  of  mind,  which  may  spell  success  or 
failure  in  her  ability  to  carry  out  her  work.  When  the  premature 
infant  gives  evidence  of  sufficient  strength  to  be  placed  upon  the 
breast,  we  have  found  the  application  of  the  wet-nurse's  baby  to 
the  other  breast  a  very  valuable  expedient  in  aiding  the  flow  of 
milk  into  the  breast  which  is  to  be  nursed  by  the  weakling.  In 
many  instances  we  have  seen  the  milk  flowT  from  the  second  breast 
by  this  method  so  freely  that  but  very  little  effort  was  required 
on  the  part  of  the  weakling  to  obtain  its  food. 


THE  HYGIENE  OF  THE  WET-NURSE. 

In  general,  everything  that  has  been  said  in  the  chapter  on 
hygiene  of  the  nursing  mother  applies  also  to  the  wet-nurse— of 
course,  with  the  proper  modifications,  made  necessary  by  peculiar- 
ities of  her  position. 

Clothes.— Her  clothes  should  be  simple,  and  in  every  part  wash- 
able. As  the  care  of  her  undergarments  is  of  even  greater  import- 
ance than  her  outer  clothing,  it  is  well  that  her  laundry  should  be 


120 


WET-NURSING 


done  with  the  family  work,  so  that  the  family  laundress  who  is 
trusted  by  the  family  may  be  charged  with  its  inspection. 


Fig.  56. — Wet-nurse  uniform.  Her  dress  should  be  of  a  simple  type,  and  made  of 
a  material  of  different  color  from  that  worn  by  the  nursing  staff.  One  lapel  of  dress 
raised  and  thrown  over  shoulder,  one  lapel  of  undervest  raised  and  breast  exposed 
for  nursing. 


To  simplify  nursing  or  the  drawing  of  milk,  the  author  has 
devised  two  garments  for  wet-nurses.     The  material  used  for  the 


Fig.  57.— Wet-nurse  uniform.     Undervest,  with  one  lapel  raised,  exposing  breast. 

outer  garment  is  of  yellow  gingham,  such  as  is  used  in  the  making 
of  hospital  uniforms— the  yellow  color  being  selected  to  distinguish 


THE  HYGIENE  OF  THE  WET-NURSE  121 

the  wet-nurse  from  the  blue,  as  used  by  the  nursing  corps.  The 
corset-waist  is  to  be  made  of  heavy  muslin.  The  corset,  if  worn 
at  all,  should  be  of  a  very  low  type  so  as  to  avoid  ;dl  pressure  on 
the  breasts.  It  is  best  of  a  cheap  quality  so  that  it  can  be  replaced 
frequently  for  sanitary  reasons.  Each  wet-nurse  should  be  supplied 
with  four  uniforms  and  six  nursing  corset-waists  (Figs.  ">(>  and  57). 

The  Diet  of  the  Wet-nurse.— There  is  danger  of  the  creation  of 
indolent  habits  through  neglect  of  regular  exercise  and  the  lack  of 
regular  household  duties,  but  even  greater  danger  lies  in  the  direc- 
tion of  overfeeding  with  unusual  foods.  The  average  wet-nurse 
is  either  obtained  from  an  institution  or  a  home  in  which  the  luxu- 
ries of  life  are  limited,  and  she  has  been  accustomed  to  a  simple 
nutritious  diet.  Every  attempt  should  be  made  to  supply  the 
nursing  woman  with  a  well-rounded  diet  of  simple  foods,  with 
milk  and  cereals  as  the  basis,  and  these  supplemented  with  meats, 
soups,  the  common  vegetables,  limited  amounts  of  fruits  and 
plain  desserts.  Insofar  as  possible  the  aromatic  vegetables,  unripe 
and  highly  acid  fruits,  fried  meats  and  rich  pastries  are  to  be 
avoided.  We  believe  that,  on  the  whole,  too  great  stress  has 
been  laid  upon  the  danger  of  the  diet  in  the  mother  of  a  full-term 
infant,  and  in  most  cases  the  average  mother  can  partake  of  a  very 
full  diet.  However,  in  the  case  of  the  woman  nursing  premature 
infants,  it  should  become  a  custom  to  allow  only  such  foods  during 
the  first  few  days  after  her  installation  as  can  be  given  with  perfect 
impunity.  When  a  full,  free  flow  of  milk  is  established  other  vege- 
tables and  fruits  can  be  added,  one  at  a  time,  and  after  each  addi- 
tion to  the  diet  a  try-out  should  be  given  the  milk.  We  have  on 
numerous  occasions  seen  marked  intestinal  distention  and  diar- 
rheal attacks  following  even  seemingly  slight  indiscretions  of  the 
diet  on  the  part  of  the  wet-nurse. 

The  diet  should  be  so  constituted  as  to  meet  the  following 
requirements : 

1.  Furnish  enough  food  of  the  proper  kind  to  satisfy  hunger 
and  meet  the  physiological  requirements  of  her  body  and  produce 
a  milk  of  good  quality.  This  includes  keeping  the  food  elements 
in  their  proper  proportions. 

2.  Prevent  the  presence  of  any  obnoxious  substances  in  the  milk. 

3.  Prevent  gastric  and  intestinal  indigestion,  constipation,  or 
anemia  in  the  wet-nurse. 

4.  Maintain  the  weight  of  the  wet-nurse  with  little  or  no  varia- 
tion. 

It  is  our  hospital  practice  to  furnish  each  wet-nurse  with  two 
quarts  of  good  wholesome  milk  daily,  and  at  least  one  pint  of 
cereal  gruel,  preferably  farina  or  cornmeal.  A  mixture  of  milk 
and  cereal  gruels  makes  a  very  good  combination  for  drinking 


122  WET-NURSING 

midway  between  meals.  The  remainder  of  the  milk  may  be  taken 
with  the  meals,  either  pure  or  in  the  form  of  cocoa,  tea  or  weak 
coffee,  in  whichever  form  it  is  best  taken  by  the  individual  woman. 
The  latter  is  of  considerable  importance,  as  in  the  forced  diets 
which  are  required,  where  an  abundance  of  milk  is  demanded, 
distasteful  foods  soon  become  obnoxious. 


DIET    FOR   WET-NURSES,    PARTICULARLY   FOR   PREMATURE 
BABIES. 

Meats.— Beef,  lamb,  chicken,  fish,  bacon. 

Eggs.— Soft  cooked  only. 

Vegetables.— Potatoes,  carrots,  spinach,  lettuce  (no  vinegar), 
beets,  string  beans,  canned  corn,  squash,  asparagus,  celery. 

Fruits.— Prunes,  apples,  oranges,  peaches,  pears,  apricots,  rasp- 
berries, blackberries,  cherries,  strawberries  (stewed  only). 

Cereals.— Rolled  oats,  rice,  farina,  cream  of  wheat,  hominy 
grits,  Wheatena,  Pettyjohn's  and  all  cooked  wheat,  oats,  rice  and 
corn  cereals. 

Fats.— Cream,  butter,  olive  oil. 

Desserts. — Soft  puddings,  gelatines. 

Breads.— Wheat,  rye,  bran,  corn,  crackers,  zwieback,  coffee 
cakes  and  plain  cakes. 

Liquids. —  Milk,  buttermilk,  kazol,  cocoa,  weak  tea  and  coffee, 
malted  milks. 

Soups.— Broths  and  soups  made  with  beef,  chicken  or  lamb. 
Vegetable  soups  made  with  milk  or  with  meat  stock  and  vegetables. 

A  void.— Aromatic  vegetables  (onions,  cabbage,  turnips,  cauli- 
flower) ;  acid  vegetables  (tomatoes,  pie-plant,  cucumbers) ;  acid 
fruits;  highly  spiced  or  seasoned  foods;  salads  with  acid  dressings; 
raw  fruits,  except  oranges;    fried  foods. 

MENU   FOR   ONE   DAY. 

Breakfast: 

Fruit  (orange,  prunes  or  apple-sauce) . 

Cereal  with  cream  and  sugar. 

Bacon  (2  slices),  or  some  other  easily  digested  meat  if  desired. 

Bread,  toast  or  rolls. 

Butter. 

Cocoa  or  milk  or  weak  coffee. 
Dinner: 

Broth  or  soup. 

One  meat  from  list  given  (roast  beef  or  broiled  chop). 

Potatoes  (old)  in  any  form  except  fried. 

Vegetables  (squash,  beets). 


THE  HYGIENE  OF  THE  WET-NURSE  123 

Light  dessert  (custard,  gelatin). 

Bread  (white,  rye  or  bran). 

Butter. 

Cocoa  or  milk  or  weak  tea  or  coffee. 
Supper: 

One  meat  from  list  given  (chicken). 

Potatoes  (creamed). 

One  vegetable  (asparagus). 

Cereal  with  cream  and  sugar  (rice). 

Stewed  fruit  (peaches). 

Bread  and  butter. 

Cake  occasionally. 

Milk  or  cocoa. 
No  candies  should  be  allowed  except  as  a  dessert  with  one  of  the 
main  meals. 

If  the  nurse's  appetite  demands  more  food  because  of  the  large 
amount  of  milk  secreted,  or  if  insufficient  fluids  are  taken  with 
the  meals  to  cover  the  fluid  requirements,  as  previously  stated,  one 
or  two  midday,  and  one  night  luncheon  may  be  given.  These 
should  consist  of  milk,  milk  and  tea,  malted  milk  or  cereal  decoc- 
tions, with  crackers,  coffee  cake,  etc. 

Beers,  malt-extracts  and  other  rich  drinks  are  not  forced  upon 
the  nurse  unless  she  is  accustomed  to  them,  and  feels  their  need. 
It  must  always  be  remembered  that  an  excess  of  fluids  would 
naturally  tend  to  dilute  the  milk  unless  the  secreting  gland  be  of 
exceptional  development.  Excessive  feeding  by  giving  of  too  fre- 
quent meals  in  the  presence  of  anorexia  will  retard  rather  than 
increase  the  milk  flow. 

Exercise  of  the  Wet-nurse  and  Her  Work.— She  should  be  impressed 
before  her  engagement  with  the  fact  that  she  will  be  required  to 
do  a  moderate  amount  of  work  and  exercise  regularly  out  of  doors. 
The  former  will  be  of  service  in  promoting  her  general  health,  and 
both  the  work  and  the  exercise  will  serve  as  a  nerve  tonic  and  pre- 
vent her  becoming  indolent.  This  does  not  mean  that  she  should 
become  a  drudge,  but  that  she  should  at  least  be  required  to  care 
for  her  own  room  and  her  own  infant's  clothes,  and  should  be  made 
to  feel  that  in  return  for  her  laundry  work  she  would  be  requested 
to  do  some  light  general  wTork  about  the  house.  Her  exercise  in 
the  open  air  should  so  far  as  possible  be  at  regular  times.  The 
question  as  to  the  care  of  the  napkins  of  both  babies  is  open  to 
considerable  discussion;  and  it  may  be  stated  that  whenever  it 
becomes  necessary  for  the  nurse  to  express  her  milk  by  hand,  she 
should  not  be  subjected  to  the  handling  of  soiled  napkins,  whenever 
this  can  be  avoided. 


124  WET-NURSING 


OTHER  CONDITIONS  INFLUENCING  THE  QUALITY  OF 
THE  BREAST  MILK. 

The  Nervous  and  Mental  State  of  the  Nurse.— The  nervous  and 
mental  state  of  the  nurse  is  of  the  utmost  importance,  and  wherever 
possible  an  emotional,  nervous,  erratic  woman  should  be  excluded, 
because  of  the  tendency  of  these  influences  to  suppress  the  flow  of 
milk.  Therefore,  whenever  possible,  a  woman  of  more  or  less 
phlegmatic  temperament  is  to  be  selected.  This  is  especially  true 
in  the  case  of  a  woman  who  is  to  be  in  close  contact  with  and  is 
to  nurse  an  infant  with  neurotic  tendencies.  There  is  also  the 
possibility  of  the  same  influence  being  manifest  in  time  of  slight 
indisposition  on  the  part  of  her  own  infant,  and  such  an  indi- 
vidual is  also  more  likely  to  resent  the  necessity  of  partial  or  entire 
artificial  feeding  of  her  own  child  to  the  advantage  of  the  premature 
infant,  when  it  has  reached  such  an  age  when  it  may  make  greater 
demands  on  her  supply. 

Menstruation.— Menstruation  rarely  produces  any  serious  dis- 
turbances. It  is  always  a  safe  procedure  to  dilute  the  milk  during 
the  first  and  second  day  of  menstruation  when  the  nurse  suffers 
considerable  pain  at  these  times. 

Period  of  Lactation.— Period  of  lactation  may  or  may  not  be  a 
considerable  factor,  depending  upon  the  individual  woman.  We 
had  in  our  employ  a  nurse  who  had  been  with  the  institution  for 
sixteen  and  a  half  months,  and  whose  infant  was  eighteen  months 
old,  and  who  supplied  us  with  the  largest  quantity  and  the  best 
quality  of  milk  of  the  four  nurses  in  the  institution.1 

When  possible  a  nurse  should  be  selected  after  the  first  few 
weeks  of  lactation,  at  which  time  the  colostrum  has  disappeared 
from  the  milk,  and  the  quantity  and  quality  of  her  milk  has  become 
established.  After  the  first  few  weeks  of  lactation  but  little  or 
no  attention  is  to  be  paid  to  the  age  of  the  wet-nurse's  baby  as 
compared  with  that  of  the  infant  to  be  fed,  and  we  have  never 
noted  any  ill  effects  following  the  rule. 

1  The  milk  of  this  nurse  was  examined  in  the  laboratories  of  the  University  of 
Chicago  after  seventeen  months  of  lactation  with  the  following  result: 

Albumin 1.30  percent 

Casein 0.69  " 

Fat 3.54  " 

Lactose 7.025  " 

Salts 0.1885        " 

It  must  be  remembered  that  this  is  an  exceptional  case,  and  but  few  women 
under  the  stress  of  ordinary  life  can  properly  nurse  their  infants  after  the  ninth  to 
twelfth  month. 


THE  NURSING  125 


THE  NURSING. 


The  Infant's  Bedroom.— Under  ideal  circumstances,  this  should 
be  separated  from  that  of  the  wet-nurse.  This  is  especially  true 
where  a  trained  attendant  has  care  of  the  infant.  It  should  under 
all  circumstances  also  be  separated  from  the  wet-nurse  when  she 
is  of  a  low  degree  of  intelligence  and  of  a  type  not  to  be  trusted 
with  the  care  of  the  infant. 

Method  of  Drawing  Milk.— Numerous  methods  of  obtaining  milk 
from  the  breasts  have  been  described,  but  only  those  most  practi- 
cable of  application  will  be  detailed.  These  should  be  divided:  (1) 
Into  those  in  which  the  baby  is  placed  directly  at  the  breast,  and 
(2)  those  methods  by  which  the  milk  is  drawn  from  the  breasts 
and  fed  to  the  infant.  Two  methods  are  especially  applicable 
where  the  baby  is  fed  directly  on  the  breast,  and  needs  assistance 
because  of  its  weakness. 


Fig.  58. — Proper  method  of  holding  baby  during  nursing.     The  nurse  is  seated  on  a 
low  nursing  chair  with  her  right  foot  elevated  on  a  low  stool. 

1.  The  premature  infant  is  placed  at  the  breast,  and  is  sup- 
ported there  by  the  nurse's  right  arm  while  nursing  at  the  right 
breast,  and  the  left  hand  is  used  to  grasp  the  breast  just  above 
the  nipple  between  two  fingers  and  the  milk  is  expressed  directly 
into  the  baby's  mouth.  In  this  way  the  baby  is  taught  to  take  the 
breast,  and  at  the  same  time  receive  its  food  with  little  effort. 


126 


WET-NURSING 


This  method  can  be  continued  until  the  baby  has  gained  sufficient 
strength  to  nurse  without  assistance. 

2.  Much  the  same  result  can  be  accomplished  by  placing  the 
wet-nurse's  baby  on  the  opposite  breast  during  the  nursing  period, 
whereupon  the  simultaneous  nursing  on  both  breasts  will  cause  a 
free  flow  of  milk  into  both  sides. 

The  methods  by  which  the  milk  is  drawn  from  the  breasts  and 
fed  to  the  infant  by  hand  or  by  other  means  are : 

1.  By  the  breast-pump.  The  modification  of  Holz  vacuum 
apparatus,  as  devised  by  the  author  (Fig.  60),  by  which  means  the 
milk  is  drawn  directly  into  two  graduated  2-ounce  flasks,  which 


Fig.  59. — Premature  infant  nursing  one  breast  and  wet-nurse's  baby  nursing  the 
other.  If  there  is  a  choice  of  breasts  the  premature  should  have  the  better  one 
reserved  for  its  use.  This  leaves  the  strong  infant  to  develop  the  poor  breast.  If 
the  premature  is  unable  to  empty  its  breast,  nursing  should  be  followed  by  expression 
or  application  of  the  wet-nurse's  baby,  if  both  are  well. 

can  be  filled  to  the  quantity  desired,  and  stoppered  for  future  use, 
so  that  the  milk  is  free  from  handling,  and  thereby  avoid  con- 
tamination. This  type  as  well  as  other  hand  pumps  are  less  practical 
than  drawing  milk  by  expression.  Dr.  I.  A.  Abt,  of  Chicago,  has 
recently  designed  an  electric  breast-pump  which  promises  to  be  of 
great  value.1 

2.  By  direct  expression  which  is  by  all  odds  the  method  of  choice 
and  which  is  performed  as  follows: 

Scrub  the  hands  and  nails  with  soap,  warm  water,  and  a  nail- 
brush for  at  least  one  full  minute.     Wash  the  nipple  with  fresh 


1  Tr.  Am.  Ped.  Soc,  1921. 


THE  NURSIXd  127 

absorbent  cotton  and  boiled  water  or  a  freshly  made  boric  solution. 
Dry  the  hands  thoroughly  on  a  clean  towel  and  keep  them  dry. 
Have  a  sterilized  graduate  glass  tumbler  or  large-mouthed  bottle 
to  receive  the  mi!k 

(a).  Grasp  the  breast  gently  but  firmly  between  the  thumb  placed 
in  front  and  the  remainder  of  the  fingers  on  the  under  surface  of 
the  breast.  The  thumb  in  front  and  the  first  finger  beneath  should 
rest  just  outside  of  the  pigmented  area  of  the  breast. 

(b).  With  the  thumb  a  downward  pressing  motion  is  made  on  the 
front  against  the  fingers  on  the  back  of  the  breast,  and  the  thumb 
in  front  and  fingers  behind  are  carried  downward  to  the  base  of 
the  nipple. 


^ J 

^    ...    r.                           || 

f?  - 

kk. 

**■   ijHB^ 

*Ld 

-  iB 

—     ^H 

Fig.  60. — The  pump  is  made  in  two  types,  the  first  fitted  with  a  large  rubber  bulb 
of  a  size  considerably  larger  than  is  ordinarily  sold  with  breast  pump,  and  the  second 
attachment  to  which  the  Holz  vacuum  pump  can  be  fitted.  In  place  of  the  ordinary 
collecting  bulb  at  the  lower  surface,  an  arm  is  so  constructed  as  to  allow  the  milk  to 
flow  into  specially  designed  graduated  2-ounce  milk  flasks. 


(c).  This  second  act  should  end  with  a  slight  forward  pull  with 
gentle  pressure  at  the  back  of  the  nipple,  which  causes  the  milk 
to  flow  out. 

The  combination  of  these  three  movements  may  be  described  as 
"  back-down-out." 

It  is  not  necessary  to  touch  the  nipple. 

This  act  can  be  repeated  thirty  to  sixty  times  a  minute  after 
some  practice. 

Both  breasts  may  be  emptied  if  necessary,  or  they  may  be  used 
alternately. 

The  act  should  be  carried  through  with  such  gentleness  as  to 
cause  little  or  no  inconvenience  to  the  nurse  even  in  the  first  days 


128 


WET-NURSING 


Fig.  61.  —  Direct  expression,  first  motion. 


Fig.  62. — Direct  expression,  second  motion. 


HOSPITAL  RULES  FOR  HANDLING  WET-NURSES        129 

of  lactation.  Some  nurses  prefer  to  use  one  hand  for  both  breasts, 
others  become  ambidextrous  and  prefer  to  change  hands. 

By  this  means,  following  a  little  practice,  the  nurse  can  express 
from  6  to  8  ounces  of  milk  from  two  good  breasts  in  fifteen  to 
twenty  minutes.  While  drawing,  each  2  ounces  of  milk  is  poured 
directly  into  sterile,  stoppered  bottles  to  prevent  the  fingers  of 
the  nurse  coming  in  contact  with  the  milk  by  overfilling  the  glass. 

The  milk  should  be  covered  at  once  by  a  sterile  cloth  held  in 
place  by  a  rubber  band  and  kept  on  ice  until  used. 

Daily  Number  of  Expressions.— Expression  is  performed  six  times 
daily  at  regular  intervals  of  four  hours  during  the  day  and  night. 

HOSPITAL  RULES  FOR  HANDLING  WET-NURSES. 

Samples  of  breast  milk  should  be  examined  from  each  wet-nurse 
at  regular  intervals.  Her  breasts  and  method  of  expression  should 
be  inspected.  It  is  not  uncommon  for  wet-nurses  to  dilute  their 
milk  by  adding  cows'  milk  to  increase  the  quantity  when  they 
experience  a  shortage. 

Sick  babies  are  not  permitted  to  nurse  from  the  wet-nurses' 
breasts;  the  expressed  milk  should  be  fed  to  the  sick  baby,  when- 
ever possible  while  it  is  yet  warm. 

If  there  be  any  question  as  to  the  reliability  of  the  wet-nurse 
the  milk  must  be  drawn  in  the  presence  of  a  second  person. 

Wet-nurses  for  prematures  must  not  be  allowed  to  go  to  a  gen- 
eral table  for  their  meals,  but  must  have  their  meals  brought  to 
them  where  they  may  partake  of  their  food  under  the  eye  of  a  nurse 
who  understands  what  their  diet  is  to  be.  Wet-nurses  have  pre- 
carious appetites,  as  a  rule,  and  they  are  more  likely  than  not  to 
have  a  craving  for  something  that  will  either  diminish  the  amount 
of  their  milk  or  impart  some  condition  that  will  make  it  disagree 
with  the  sick  babies. 

Wet-nurses  should  be  kept  rigidly  within  regular  hours  in  the 
institution.  They  should  not  be  permitted  to  go  out  after  night 
because  they  will  do  indiscreet  things,  eat  foods  calculated  to 
interfere  with  their  efficiency  as  wet-nurses,  drink  alcoholic  stimu- 
lants, and  so  upset  themselves  generally  and  the  milk  supply  will 
be  diminished.  On  the  other  hand,  the  wet-nurses  should  be 
made  comfortable,  and  should  be  given  a  sufficient  amount  of 
work  in  the  institution  to  keep  them  busy.  They  are  disposed  to 
resent  restraint  and  unless  their  time  is  fully  occupied,  they  will 
be  sure  to  fret  and  thus  diminish  their  milk  supply. 

The  wet-nurse  should  be  obliged  to  observe  the  laws  of  health 
and  cleanliness;  they  should  be  obliged  to  bathe  regularly  and  it 
should  be  the  duty  of  the  head  nurse  of  the  department  to  see  that 
9 


130  WET-NURSING 

their  bowels  are  kept  in  proper  condition  and  that  their  genitals 
are  clean  and  healthy. 

Wet-nurses  should  never  be  employed  until  the  Wassermann 
test  has  been  made,  and  until  a  competent  physician  has  given 
them  a  thorough  examination  to  determine  the  presence  or  absence 
of  specific  disease.  They  should  never  be  permitted  to  go  on 
duty  with  running  ears,  sore  eyes,  sore  throat,  bad  teeth  or  any 
discharge  from  a  mucous  membrane,  or  any  skin  eruption. 

The  wet-nurse  should  be  given  a  certain  number  of  babies  to 
feed,  and  as  long  as  her  milk  agrees  with  them,  and  she  is  in  perfect 
health,  should  be  kept  to  the  same  babies  without  any  admixture 
of  the  milk  of  any  other  nurse  This  acts  as  a  check  on  any 
indiscretion  as  it  would  be  reflected  in  the  baby. 


CHAPTER    VII. 
(ARE  AND  NURSING  OE  PREMATURE  INFANTS. 

All  infants  born  three  weeks  or  more  before  full  term  should 
be  considered  premature  and  treated  as  such.  Every  infant 
born  after  the  sixth  month  should  be  given  an  opportunity  for 
life  by  the  administration  of  necessary  care  and  diet.  Healthy 
premature  infants  when  properly  cared  for  will  frequently  reach 
the  full  development  of  the  full-term  infant  by  the  end  of  the 
first  year,  and  the  majority  of  those  surviving  usually  develop  a 
normal  body  and  mind,  notwithstanding  the  fact  that  they  are 
more  commonly  subject  to  megacephalus,  rickets,  spasmophilia, 
anemia,  gastro-intestinal,  respiratory  and  circulatory  affections, 
all  of  which  can  be  overcome  without  leaving  any  sequelae,  unless 
based  upon  some  congenital  anomaly. 

To  be  successful  with  these  infants  a  certain  routine  must  be 
followed : 

1.  Preparation  for  their  home  or  hospital  care  must  be  made, 
whenever  possible  before  labor  begins. 

2.  Their  immediate  care  after  birth  is  of  greatest  importance. 

3.  Their  general  care  must  be  adapted  to  their  individual  needs. 
(a)  Refrigeration  must  be  prevented. 

(6)  Skilled  nursing  is  essential. 

4.  Human  milk  must  be  provided  for  those  born  before  the 
thirty-sixth  week. 

5.  The  daily  routine  must  be  adapted  to  the  infant's  age  and 
development. 

6.  Contact  between  the  infant  and  individuals  not  concerned  in 
its  immediate  care  must  be  avoided.  Attendants  ill  with  colds 
and  other  forms  of  infection  should  observe  most  rigid  rules  of 
asepsis  to  avoid  cross  infections. 

PREPARATIONS  FOR  THE  INFANT'S  BIRTH. 

In  case  of  expected  premature  labor  immediate  preparations 
must  be  made  for  the  reception  of  the  infant  into  a  proper 
environment.  The  preparation  must  not  be  delayed  until 
labor  has  begun,  otherwise  many  viable  premature  infants  will 
be  lost.  If  the  proper  facilities  cannot  be  furnished  in  the 
home,     the    mother    should    be    persuaded     to    enter    a    hos- 


132  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

pital  before  confinement.  She  should  be  impressed  with  the 
fact  that  every  day  of  added  intra-uterine  life  will  improve  the 
infant's  chances  not  only  for  life,  but  also  for  normal  development. 
Preparation  for  the  proper  conduct  of  labor  should  be  complete 
whether  in  the  home  or  hospital.  The  mother  should  be  prepared 
with  great  care  and  every  effort  made  to  conduct  an  aseptic  labor. 
The  room  should  be  selected  and  prepared  to  meet  the  needs  for 
labor  and  the  requirements  of  the  infant.  It  should  be  well  venti- 
lated and  properly  heated  to  at  least  70°  F.  Blankets  and  pads 
into  which  the  baby  is  to  be  received  should  be  warmed.  The 
basket-bed  or  incubator-bed  should  be  prepared  for  its  reception 
by  proper  sterilizing  and  heating,  so  that  all  exposure  to  cold  will 
be  avoided.  Everything  must  be  in  readiness  for  the  care  of  the 
cord,  eyes,  mouth,  skin  and  treatment  of  asphyxia.  These  should 
include  a  catheter  and  hot  bath,  and  facilities  for  transportation 
of  the  infant  to  a  hospital,  if  necessary. 

IMMEDIATE  CARE  OF  THE  PREMATURE  INFANT. 

Asepsis.— The  greater  susceptibility  of  the  prematures  demands 
even  more  painstaking  observation  of  the  rules  that  hold  good  for 
new-born  infants  in  general.  These  infants  succumb  more  readily 
to  infection  and  are  much  less  resistant  than  are  the  full-term 
infants.  Again,  the  frequently  complicated  feeding  technic  gives 
more  opportunity  for  disturbances  of  the  digestive  tract  so  that 
in  every  form  of  indirect  feeding  careful  attention  to  details  must 
be  insisted  upon.  Also  the  danger  of  infection  of  the  respiratory 
passages  by  careless  exposure  and  aspiration  of  food  are  not  to  be 
underestimated. 

Reception  of  the  Infant.  A  warm  sterile  pad,  towel  or  preferably 
a  blanket  should  be  in  readiness  to  receive  the  infant.  As  soon 
as  the  head  is  born  the  face  and  eyelids  should  be  gently  sponged 
with  sterile  warm  water,  and  the  mucus  should  be  removed  from 
the  air  passages  by  carefully  wiping  the  nose  and  mouth  with  a 
soft  pledget  of  gauze.  The  body  and  cord  should  be  protected 
from  all  contact  with  feces  and  other  infected  matter.  After  the 
body  is  born  the  infant  should  be  placed  so  that  the  head  is 
dependent,  allowing  the  mucus  and  secretions  which  may  have 
accumulated  in  the  respiratory  passages  to  escape. 

Preservation  of  Body  Temperatures.— The  preservation  of  tempera- 
ture demands  a  very  careful  supervision  immediately  following 
birth,  proper  attention  must  be  paid  to  the  thermolability  and 
tendency  to  subnormal  temperatures.  The  chief  object  in  the 
preservation  of  the  temperature  is  the  prevention  of  excessive 
heat  loss,  which  in  itself  may  be  a  danger  to  the  infant.     This  will 


IMMEDIATE  CARE  OF  THE  PREMATURE  INFANT      133 

also  diminish  the  energy  loss.  The  infant  must  be  wrapped  in 
material  with  poor  heat  conduction,  and  then  placed  in  a  warmed 
bed.  Both  are  essential  to  a  successful  maintenance  of  body  tem- 
perature. 

The  preservation  of  heat  must  be  begun  immediately  after 
birth  of  the  infant,  preferably  on  the  confinement  bed  itself,  as  the 
extent  of  the  initial  temperature  loss  is  of  no  mean  consequence  to  a 
premature  infant.  After  severing  the  cord  the  infant  should  be 
placed  in  a  heated  basket  or  incubator-bed,  which  should  be  a 
part  of  the  equipment  of  the  delivery-room. 

In  the  home,  hot-water  bottles,  a  properly  protected  electric 
pad  (p.  224),  or  an  improvised  incubator  (p.  223)  will  answer  the 
purpose.  It  should  be  remembered  that  these  infants  are  easily 
burned  and  such  burns  are  usually  fatal. 

In  small  prematures  the  cotton-pack,  completely  enveloping  the 
infant,  except  for  the  face  and  genito-anal  region,  answers  very 
well.  To  the  genital  region  and  anus  a  napkin  of  cotton  or  gauze 
combination  may  be  applied.  A  jacket  may  be  placed  on  the 
outside  of  the  cotton  to  hold  it  in  place. 

Treatment  of  the  Cord.— The  time  of  tying  and  section  of  the  cord 
will  depend  entirely  on  the  general  condition  of  the  infant  and  to 
some  extent  on  the  obstetrician's  ability  to  prevent  undue  exposure 
of  the  infant  to  cold.  In  the  absence  of  marked  asphyxia  it  is 
well  to  allow  the  pulsation  of  the  cord  to  become  weakened  or  to 
disappear  before  ligation.  This  usually  requires  from  one  to  five 
minutes  during  which  time  the  infant  will  receive  from  30  to  60 
cc  of  blood  from  the  placenta.  This  blood  should  be  conserved, 
when  possible. 

The  cord  should  not  be  tied  too  close  to  the  skin.  Great  care 
must  be  exercised  in  tying  the  cord  to  prevent  cutting  it  in  two  with 
the  ligature  which  is  easily  accomplished  in  the  premature,  therefore 
it  is  always  well  to  leave  sufficient  space  for  a  second  ligature 
behind  the  first  in  case  of  an  accident. 

Asphyxia.— The  possibility  of  asphyxiation  of  the  premature 
infant  must  be  borne  in  mind  throughout  the  entire  labor.  The 
heart  tones  should  be  carefully  watched  and  in  cases  of  prolapse 
of  the  cord,  if  it  cannot  be  successfully  replaced,  it  may  be  neces- 
sary to  induce  a  rapid  delivery  of  the  infant.  Any  accumulated 
secretions  or  aspirated  material  must  be  removed  by  inversion  of 
the  child  and  if  necessary  by  aspiration  by  means  of  a  catheter. 
In  more  extreme  degrees  of  asphyxia  early  separation  of  the  cord 
may  be  necessary  so  that  artificial  respiration  and  a  hot  bath  may 
be  instituted  (p.  244). 

The  irritation  of  the  catheter  in  the  pharynx  will  frequently 
reflexly  stimulate  respiration.  It  should,  however,  be  remembered 
that  the  use  of  the  catheter  is  not  without  danger  to  the  operator 


134  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

because  of  the  frequency  of  syphilis  as  a  cause  of  premature  birth. 
If  these  procedures  fail  to  bring  about  the  desired  result  the  infant 
should  be  suspended  by  the  feet,  the  forehead  resting  lightly  on 
the  bed  or  table  so  as  to  deflect  the  chin  and  straighten  out  the 
trachea  and  then  the  chest  is  compressed  between  the  thumb  of 
the  right  hand  resting  on  the  back  and  the  four  fingers  of  the  same 
hand  resting  on  the  anterior  wall  of  the  chest. 

This  act  should  be  repeated  from  sixteen  to  twenty  times  a  minute 
by  compressing  and  suddenly  relaxing  the  chest  wall.  This  should 
be  continued  for  at  least  one  minute  in  severe  cases  to  insure  success. 
At  the  same  time  a  nurse  or  assistant  should  wipe  the  excess  of 
mucus  from  the  nose  and  throat.  The  child  is  then  placed  in  a 
warm  bath  (about  105°  F.)  for  five  minutes,  and  then  placed  in  a 
heated  bed.  In  extreme  cases  the  procedure  must  be  repeated. 
Administration  of  oxygen,  about  120  bubbles  per  minute,  may  be 
of  value,  if  administered  through  a  catheter  inserted  in  the  mouth 
or  a  properly  constructed  mask.  Careless  handling  and  traumatiz- 
ing the  infant  or  too  rapid  performance  of  artificial  respiration  is 
productive  of  more  harm  than  good  and  must  therefore  be  avoided. 
There  must  be  definite  indications  for  all  manipulations  undertaken. 
If  the  infant  appears  to  be  recovering  spontaneously  it  should  be 
left  alone. 

It  must  be  borne  in  mind  in  the  conduct  of  all  premature  labors 
that  the  anesthetics,  if  used  in  labor,  tend  to  weaken  the  uterine 
contractions,  thus  prolonging  labor  and  favoring  asphyxia  and  a 
sufficient  quantity  of  the  drug  may  pass  into  the  infant  to  seriously 
affect  it,  which  is  especially  true  of  scopolamine-morphine  anes- 
thesia. 

All  premature  infants  whether  asphyxiated  at  birth  or  not  should 
be  carefully  watched  for  cyanotic  attacks  during  the  first  days  of 
life,  as  such  attacks  may  develop  suddenly  and  without  warning. 
They  may  be  due  to  a  disturbance  in  the  pulmonary  circulation,  to 
a  congenital  atelectasis,  or  to  injury  of,  or  hemorrhage  into  the  respi- 
ratory center  in  the  medulla.  At  other  times  they  are  precipitated 
by  intra-abdominal  distention  which  may  interfere  with  cardiac 
or  respiratory  action.  For  further  discussion  of  this  condition  see 
Cyanosis  (p.  241). 

Care  of  the  Mouth  and  Nose.  — Every  effort  must  be  made  to  avoid 
trauma  of  the  mucous  membranes  of  the  nose  and  mouth,  because 
of  the  danger  of  secondary  infections.  Cleansing  of  the  nose 
should  be  done  by  the  use  of  soft  cotton  pledgets  or  applicators. 
In  wiping  out  the  mouth  only  soft  material  is  permissible.  Much 
can  be  accomplished  by  facing  the  child  with  the  mouth  down- 
ward or  laterally  with  the  trunk  elevated,  so  that  the  mucus  can 
gravitate  toward  the  mouth. 


GENERAL  HYGIENE  AND  ENVIRONMENT  135 

Care  of  the  Eyes.— One  per  cent  silver  nitrate  solution  or  25  per 
cent  argyrol  should  be  used  to  prevent  ophthalmia  neonatorum. 
The  nitrate  of  silver  solution  should  be  neutralized  with  a  normal 
saline  solution  instilled  in  the  eyes.  Not  infrequently  the  application 
of  silver  nitrate  will  result  in  some  inflammatory  reaction  of  the 
conjunctiva  in  the  first  six  to  twelve  hours  after  its  application. 
This  is  especially  frequent  in  premature  infants  and  is  usually 
relieved  by  the  application  of  cold  boric-acid  solution  to  the  lids. 
It  is  not  to  be  confused  with  the  more  serious  specific  ophthalmia 
which  develops  on  the  second  or  third  day.  In  case  of  doubt  a 
microscopic  examination  of  the  purulent  discharge  must  be  made. 
In  all  cases  an  old  silver  nitrate  solution  which  has  undergone 
decomposition  should  be  avoided,  as  such  solutions  are  far  more 
prone  to  irritate  the  sensitive  conjunctiva. 

Care  of  the  Skin  and  Genitalia.— It  is  of  the  greatest  importance 
that  premature  infants  shall  be  handled  as  little  as  possible.  And 
when  there  is  doubt  as  to  the  advisability  of  giving  the  initial 
warm  bath,  it  is  best  omitted,  because  of  the  danger  of  causing  a 
collapse.  When  the  bath  can  -be  given  without  chilling  it  is 
indicated  in  most  infants  weighing  1500  gm.  or  more.  In  smaller 
infants  and  those  showing  evidence  of  atelectasia  or  asphyxia,  it 
may  be  needed  to  stimulate  the  respiratory  functions.  Oiling  the 
body  is  unnecessary  and  is  to  be  avoided.  The  genitalia  should 
be  carefully  cleansed  with  a  boric-acid  solution  or  sterile  water  with- 
out trauma.  The  same  is  true  of  the  buttocks,  after  which  a  small 
pad  of  cotton  or  combination  is  applied  to  the  genitalia  and  but- 
tocks. 

Dressing  the  Cord.— Either  a  dry  or  alcohol  dressing  should  be 
applied.  The  cord  usually  dries  by  mummification  and  drops  off  in 
most  instances  by  the  end  of  the  first  week,  averaging  somewhat 
later  than  in  full-term  infants.  Every  precaution  should  be  taken 
to  prevent  trauma  of  the  stump  and  secondary  infection.  This 
applies  more  especially  to  the  bathing  of  the  infants  in  emergencies 
for  cyanotic  spells  and  hypothermia. 

Examination  for  Congenital  Anomalies  and  Disease.— Before  the 
infant  is  left  by  the  physician  it  should  be  examined  for  congenital 
anomalies  and  evidence  of  syphilis  and  other  diseases. 

GENERAL  HYGIENE  AND  ENVIRONMENT. 

Requirements  of  a  Hospital  Nursery  Unit.— This  depends  greatly 
upon  the  method  used  for  maintaining  external  heat. 

1.  Superheated  rooms  without  heated  beds. 

2.  Individual  heated  beds. 

When  the  superheated  rooms  are  in  use  separate  rooms  for  the 


130 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


GENERAL  HYGIENE  AND  ENVIRONMENT  137 

older  and  better-developed  infants  must  be  supplied  to  gradually 
accustom  them  to  ordinary  room  temperature.  However,  this  extra 
room  is  not  necessary  when  external  heat  is  applied  in  individual 
beds  in  which  the  temperature  can  be  regulated  to  meet  the  needs 
of  each  infant.  In  using  the  latter  the  room  can  be  held  at  a 
temperature  approximating  70°  F.  In  point  of  economy  of  space 
and  special  care  for  the  infant  the  latter  method  has  every 
advantage. 

When  individual  heated  beds  are  used  the  following  units  are 
required  in  a  properly  regulated  department. 

Room  Containing  Heated  Bed.— A  room  with  a  south  exposure 
is  preferable.  In  such  a  room  the  matter  of  ventilation  will 
depend  to  a  large  extent  upon  the  type  of  heated  bed  which  is 
used.  When  the  old  type  of  closed  incubator  is  used,  it  must 
necessarily  receive  fresh  air  through  a  pipe  passing  through  the 
wall  of  the  building  or  an  opening  in  a  window,  thereby  sup- 
plying the  bed  with  air  from  the  outside  (Fig.  136).  When  an 
electrically  heated  bed  or  home  improvised  bed  is  used  the  infant 
is  dependent  upon  the  general  ventilation  of  the  room  for  its  supply 
of  fresh  air. 

Such  a  room  is  best  constructed  with  double  windows  and  tran- 
som which  can  be  regulated  at  will  according  to  the  season  and 
existing  weather  conditions.  Such  a  system  of  ventilation  should 
be  sufficiently  flexible  to  permit  regulation  to  meet  exigencies 
which  may  arise  due  to  instability  of  the  general  heating  plant.  It 
has  been  our  experience  that  when  a  well-constructed  superheated 
bed  is  used,  variations  of  from  6  °  to  8°  F.  in  the  room  temperature 
during  the  twenty-four  hours  cause  little  inconvenience  to  the 
infant. 

It  should  be  remembered  that  the  beds  should  not  be  placed  in 
a  direct  line  of  draft  between  the  windows  and  the  doors.  The 
room  should  be  built  or  selected  with  this  in  mind.  Such  a  room 
should  also  contain  a  hygrometer  and  special  thermometers  which 
register  not  only  the  present  temperature  but  also  the  extremes 
for  twenty-four  hours  (Taylor  Instrument  Company).  Such  a 
thermometer  is  one  of  the  best  methods  of  testing  an  efficient 
nursery.  Further  discussion  of  incubator  rooms,  incubators,  super- 
heated beds  and  similar  apparatus  are  covered  under  the  special 
chapter  on  Incubators. 

This  room  is  to  be  used  only  for  well  new-born  prematures  in 
their  individual  beds  and  older  infants  who  have  been  gradually 
accustomed  to  ordinary  room  temperature. 

The  Nursery.— The  nursery  should  be  a  room  independent  of 
the  station  in  which  the  superheated  beds  are  kept.  It  should  be 
provided  with  double  windows,  a  good  system  of  heating,  and 


138 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


must  be  kept  immaculately  clean.     Good  ventilation  and  general 
cleanliness  are  essential.     Unless  a  special  bathroom  can  be  pro- 


Fig.  64. — Hospital  bathroom,  located  between  two  small  wards  for  infants, 
showing  two  metal  water  jackets  resting  on  a  porcelain  sink.  These  can  be  filled 
with  water  and  have  a  registering  thermometer  for  indicating  the  temperature  before 
giving  the  bath.  They  are  covered  with  a  clean  towel  for  each  baby.  Baby  is 
showered  from  an  automatic  mixing  tank  which  registers  temperature  of  the  water 
in  the  tank.  The  room  further  contains  a  scale  and  a  low  dressing  table  with  the 
various  dressings,  powders  and  ointments  to  be  used.  Also  low  nursery  chairs,  col- 
lapsible bags  for  soiled  linen  and  waste  basins. 


L 


Fig.  65.  —  Divan  bath  with  thermostatic  mixing  control. 


GENERAL  HYGIENE  AND  ENVIRONMENT 


139 


Fig.  66. — Electrically  warmed  dressing  table.     (DeLee.) 


Fig.  67. — Large  unheated  dressing  table,  provided  for  dressing  of  two  babies.     Scale 
in  center  and  closed  cabinet  for  clothes.     (Couney.) 


140 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


vided,  the  nursery  should  be  furnished  with  the  following  equip- 
ment. 


jm  w 

S/   ^ 

HH 

I  jjlj 

■]i  Mi  1 

Fig.  68. —Scale  for  weighing  infants. 


Fig.  69. — Thermometer  registering  present 
and  extreme  room  temperature  during  the 
twenty-four  hours.  It  is  to  be  adjusted  by 
a  small  magnet  once  daily. 


Fig.  70. — Hygrometer. 
Wet  and  dry  bulb. 


1.  A  bathing  slab  or  board.  We  find  a  metal  jacket  which  can 
be  filled  with  warm  water  very  serviceable  (Fig.  64).  The  Divan 
bath  with  thermostatic  mixing  valve  is  well  designed  for  this  purpose. 


GENERAL  HYGIENE  AND  ENVIRONMENT 


141 


2.  A  heated  dressing  table  provided  with  cabinets  for  storing 
and  warming  clothes. 

3.  Supply  closets  for  linens. 


Reading 

of  dry 

bulb 
ther. 

1° 

2° 

3° 

4° 

5U 

6U 

7° 

8° 

9°  10° 11° 

12u 

13° 

14° 

15° 

16° 

17° 

17.5 

18° 

18.  S 

19° 

19.5 

20° 

20.5  21° 

Relative  Hfmidity. 

05°  .   . 

95  90  85 

80 

75 

70 

66 

62 

57 

53 

48  44  40 

36  32  28  25 

23 

21  19 

17 

15 

13  12  10 

66°  .   . 

95  90  85 

so 

76 

71 

66 

62 

58 

53 

49 !45! 41 

37  33  29  26 

24 

22!  20 

is 

17 

15  13  11 

fi7°  . 

95 ! 90  85 

so 

76 

71 

67 

62 

58 

5-1 

50 

46J42 

38  34  30  1  27 

25 

23 

21 

:>o 

is 

16  15  13 

68°  .   . 

95  90  85 

SI 

76 

72 

67 

63 

59 

55 

51 

47143 

39 

35 

31  |  28 

26 

24 

23 

21 

19 

17  16 

14 
15 

69°  .   . 

95  90  SB 

81 

77 

72 

68 

0  1 

59 

55 

51 

47  44 

40 

36 

32  29 

27 

25 

24 

:>:> 

20 

19  i  17 

70°  .   . 

95  |  90  j  86 

81 

77 

72 

68 

64 

60 

56 

52 

48  44 

40 

37  33  30 

28 

26 

25 

23 

21 

20  18  17 

71°.   . 

95  90 !  86 

82 

77 

73 

m 

01 

00 

56 

53 

49 

45 

41 

38 

34 

31 

29 

27 

26 

24 

22 

21 

19 

18 

72°  .   . 

95 | 9l|  86 

S2 

7S 

73 

69 

65 

61 

57 

53 

49 

46 

42 

39 

35 

32 

30 

28 

27 

25 

23 

?,? 

20 

19 

73°  .   . 

95  91 

st; 

82 

7S 

73 

69 

65 

61 

58 

54 

50 

46 

43 

40 

36 

33 

31 

29 

28 

26 

24 

23 

21 

20 

74°  .   . 

95  91 

86 

S2 

78 

74 

70 

66 

62 

58 

54 

51 

47 

44 

40 

37 

34 

32 

30 

29 

27 

25 

24 

22  21 

75°  .   . 

96  91 

87 

82  78 

74 

70 

00 

63 

59 

55 

51 

is 

44 

41 

38  34 

33 

31 

30 

:>s 

26 

25 

23  22 

76°  .   . 

96  91 

87  83  78  74 

70 

07 

63 

59 

55 

52 

48 

45 

42 

38  35 

34 

32 

30 

29 

27 

26 

24  23 

77°  .   . 

96  91 

87  83  79  75 

71 

67 

63 

60 

56  52  49 

10 

42  39  36  34 

33  31 

30 

28 

27  25  24 

Fig.  71.  —  Humidity  table  for  use  with  wet  and  dry  bulb  hygrometer. 


Fig.  72. — A  milk  station  consisting  of  three  rooms.  Room  1. — For  all  used  bottles, 
bottle  washers  and  steam  bottle  sterilizers.  Room  2. — A  clean  room  for  preparation 
of  formulae.  This  room  also  contains  milk  separator,  fat  testing  apparatus  and 
butter  churn.     Room  3. — Pasteurizing  and  sterilizing  apparatus. 


ISCANLAN-MORRISCOl 

ISUFACTURERS 
MS   USA 


Fig.  73. — Portable  bath  basin  for  individual  use  of  infected  infants.     Basin  can  be 
removed  for  sterilization. 


Fig.  74. — Individual  bed  with  utensil  compartment  for  infected  cases. 


SPECIAL  QUARTERS  FOR  SICK  INFANTS  143 

4.  A  well-constructed  balance  scale  graduated  to  4  gm. 

5.  A  hygrometer  (Figs.  69  and  70). 

().  Thermometers  registering  the  present  and  extreme  tempera- 
tures for  twenty-four  hours  (Fig.  70) . 

7.  A  time  clock  should  also  be  provided  and  all  feedings  registered 
by  this  method,  so  that  the  supervisor  may  have  a  constant  check 
on  the  activities  of  her  assistants. 

The  general  hygiene  and  care  of  the  infant  in  the  nursery  is 
second  only  in  importance  to  an  ample  supply  of  human  milk  and 
a  maintenance  of  the  body  temperature  of  the  infant. 

Milk  Stations.— A  milk  station  for  preserving  and  dispensing 
breast  milk  and  artificial  diets  should  be  a  part  of  the  equipment 
of  every  general  and  special  hospital  (Fig.  72). 

Wet-nurses'  Quarters.— Wet-nurses' quarters  should  provide  living 
and  sleeping-rooms  for  the  wet-nurses  and  their  babies.  The  ideal 
requirements  for  such  a  unit  are  described  under  the  chapter  on 
Wet-nurses,  p.  117. 

A  shower  bath  and  toilet  facilities  should  be  provided  for  the 
special  use  of  wet-nurses  but  not  in  living  quarters. 


SPECIAL  QUARTERS  FOR  SICK  INFANTS. 

It  is  of  the  greatest  importance  that  infected  premature  infants 
be  grouped  according  to  their  ailments  and  that  complete  facilities 
for  caring  for  these  infants  be  established,  in  order  to  avoid  cross 
infections.  Two  such  units  should  be  provided  whenever  it  is 
expected  that  a  considerable  number  of  premature  infants  are  to 
be  cared  for,  and  should  include  facilities  for  bathing,  feeding,  and 
the  general  care  of  patients.  Gastro-intestinal  and  respiratory 
infections  must  be  kept  separated  and  treated  as  septic  cases. 
Syphilitic  infants  and  cases  of  gonorrheal  ophthalmia  must  also  be 
provided  with  separate  quarters.  Thrush  and  furunculosis  which 
frequently  develop  into  severe  types  should  also  be  isolated. 

Aseptic  nursing  is  imperative  to  the  welfare  of  the  department. 
Soiled  linens,  clothes,  bottles,  thermometers  and  all  other  utensils 
must  be  handled  as  infected  material. 

A  complete  department  should  therefore  provide  for: 

A.  Well  Infants.— A  room  containing  heated  beds  for  the  early 
care  and  cribs  for  graduates.  The  further  needs  are:  A  heated 
dressing  table,  a  supply  closet,  thermometer  (high  and  low),  hygrom- 
eter, time  clock,  electric  heater  for  emergency,  screens  and  a 
lavatory. 

A  nursery  with  bathing  facilities,  supplied  with:  A  bath  slab,  a 
lavatory,  a  heated  dressing  table,  shelves  for  toilet  articles,  a  gas 


144  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

or  electric  plate,  an  electric  heater  for  emergency,  a  scale,  ther- 
mometer, supply  closet. 

A  special  bath-room  when  possible  should  be  provided  so  that 
bathing  in  the  nursery  may  be  avoided. 

Quarters  for  wet-nurses  with  independent  bath  and  toilet  facili- 
ties, equipped  with:   Beds,  cribs,  chiffoniers,  dressing  table,  nursery 


Fig.  75. — Emergency  robe  with  hood  made  of  gauze  and  cotton  combination. 

chairs  and  lavatory.  The  bath  room  should  have  a  shower  bath, 
dressing  room,  toilet  and  lavatory. 

A  milk  station  containing  a  sink,  refrigerator,  work  table,  tubs 
for  washing  utensils,  steam  sterilizer,  bottle  and  food  racks. 

Nursing  staff  including  a  directing  nurse  and  assistants. 

Wet  nurses. 


SPECIAL  QUARTERS  FOR  SICK  INFANTS  145 

B.  Infected  Infants. — Room  equipped  with  heated  beds  and  cribs 
and  provided  with  bathing  facilities.  This  room  should  further 
contain  a  lavatory,  heated  dressing  table,  scale,  thermometer, 
hygrometer,  emergency  electric  heater,  supply  closet  and  screens. 
The  bath  tub  in  this  room  may  be  of  the  small  ambulatory  type 
or  of  the  Divan  slab  type.     Both  may  be  easily  sterilized. 


Fig.  76. — Emergency  robe  applied  to  infant. 

The  nursery  should  be  considered  as  the  center  of  the  unit  and 
when  a  separate  bath  room  is  provided,  the  former  may  be  used 
for  housing  the  graduates.  The  temperature  of  this  room  should 
range  between  78  and  80°  F.  during  the  hour  of  bathing,  at  other 
times  70  to  75°  F.  The  entire  station  must  be  thoroughly  cleaned 
10 


146  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

at  least  every  second  day  and  disinfected  by  scrubbing  immediately 
after  the  diagnosis  and  removal  of  infectious  cases. 

The  Nursery  Staff.— The  selection  of  a  personnel  for  the  nursing 
staff  of  a  unit  established  for  the  care  of  premature  infants  requires 
great  care.  Nurses  assuming  these  responsibilities  must  be  intensely 
interested  in  their  work.  They  must  be  willing  to  make  many 
necessary  sacrifices  while  the  infant  is  passing  through  the  critical 
stages.  They  must,  at  all  times,  be  prepared  to  meet  the  emergen- 
cies of  asphyxia  and  to  counteract  the  spells  of  cyanosis.  These 
two  factors  in  themselves  require  almost  constant  diligence,  other- 
wise the  work  of  previous  days  will  go  unrewarded.  They  must 
use  good  judgment  to  prevent  over-  and  underfeeding,  as  to  a  very 
great  extent  the  size  of  the  individual  meal  will  be  dependent  upon 
the  physical  condition  of  the  infant  at  the  time  of  feeding.  In  no 
other  class  of  patients  is  it  so  necessary  to  change  or  modify  on 
short  notice  previous  orders  for  diet.  The  nurse  must  know  the 
indications  for  and  the  methods  of  administering  catheter  feedings, 
colonic  flushing,  tubbing  and  the  application  of  artificial  respiration. 

In  our  hospital  wards  we  have  found  the  constant  changing  of 
nurses,  as  is  so  frequently  the  case  in  meeting  the  curriculum  for 
nurses'  training  in  general  hospitals,  to  be  of  the  greatest  dis- 
advantage. Far  better  results  are  obtained  when  the  nurse  in 
charge  has  under  her  care  assistants  who  need  not  necessarily  be 
nurses  in  training,  but  preferably  young  women  who  are  especially 
preparing  themselves  for  the  care  of  young  infants,  and  who  can 
be  relied  upon  to  stay  in  the  station  for  long  periods  of  time.  Such 
women  become  expert  in  the  handling  of  these  infants,  can  fre- 
quently feed  them  with  a  minimum  of  excitement  of  their  reflexes, 
and  soon  learn  to  bathe  and  give  them  their  exercise  and  massage, 
which  is  so  essential  to  every  infant  in  order  to  prevent  "  hospitali- 
zation." 

The  ideal  nursing  staff  for  such  a  station  is,  therefore,  one  con- 
sisting of  a  well-trained  supervising  nurse  and  a  corps  of  assistants 
desiring  this  training,  and  who  are  willing  to  remain  in  this  service 
for  a  long  period  of  time. 


DAILY  ROUTINE. 

Removal  of  Infants  from  Their  Beds.— The  position  of  the  infant 
in  bed  should  be  changed  at  regular  intervals.  The  removal  of 
infants  from  their  beds  should  be  practised  with  forethought.  The 
small  infants  should,  so  far  as  possible,  be  manipulated  only  upon  a 
definite  indication:  (1)  For  cleanliness,  including  bathing;  (2) 
exercise,  including  gentle  massage  after  the  first  week  or  two.     In 


DAILY  ROUTINE  147 

most  instances  the  food,  when  administered  other  than  by  catheter, 
can  be  given  without  removing  the  baby  from  the  bed.  ( 'atheter 
feeding  in  infants  not  subject  to  cyanotic  spells  can  often  be  per- 
formed to  advantage  without  removal  from  the  bed.  When  cya- 
nosis is  present  or  easily  precipitated  the  infant  should  be  removed 
from  the  bed  during  feeding. 

In  preparing  the  infant  for  permanent  removal  from  the  heated 
bed  the  room  temperature  should  be  gradually  lessened  until  70°  F. 
is  approached. 

Next  the  infant  is  placed  in  an  infant's  crib,  the  sides  of  which 
have  been  padded  to  prevent  extreme  currents  of  air  from  coming 
in  contact  with  the  infant  and  thereby  increasing  radiation.  These 
cribs  may  remain  in  the  same  room  as  the  individual  heated  beds, 
or  may  be  kept  in  the  nursery  if  it  be  the  more  desirable  room  of 
the  two,  when  there  is  a  separate  bath  room.  The  infant  should 
not  be  kept  permanently  in  a  room  in  which  a  considerable  number 
of  infants  are  being  bathed  throughout  the  day.  There  is  no  need 
for  shortening  the  stay  of  the  infant  in  the  heated  bed  if  the  tem- 
perature of  the  surrounding  air  is  gradually  being  lowered  as  the 
infant  develops.  Depending  upon  the  age  and  development,  the 
average  length  of  time  in  a  heated  bed  varies  from  one  to  six  weeks. 
It  is  good  practice  to  place  the  older  infants  in  the  crib  during  the 
day  and  to  replace  them  in  the  heated  bed  during  the  night  when 
the  heating  of  the  house  or  ward  is  uncertain. 

The  Bath.  — In  the  very  weak  infants  it  is  frequently  advisable  to 
omit  the  first  and  the  daily  bath  for  two  or  three  days.  It  may, 
however,  be  necessary  to  use  the  warm  bath  to  stimulate  the  infant 
during  its  cyanotic  attacks. 

It  should  be  a  fixed  rule  in  the  care  of  premature  infants  to 
handle  them  as  little  as  possible,  because  of  the  danger  of  provoking 
cyanotic  attacks  and  the  regurgitation  of  food.  It  should  be  our 
object  to  keep  the  skin  clean  and  active.  The  practice  of  oiling 
the  infant  as  a  routine  measure  is  to  be  avoided.  If  the  bath 
cannot  be  undertaken  without  danger  of  chilling  the  infant,  it 
should  be  either  dispensed  with  or  postponed  for  a  more  opportune 
time;  or  a  partial  bath  may  be  given  without  removing  it  from  the 
heated  bed  by  washing  the  face,  buttocks  and  genitalia. 

Indications  for  and  Methods  of  Administering  Baths.— The  earliest 
baths  should  consist  of  a  sponging  with  water  at  105°  F.,  one  part 
of  the  body  only  being  exposed  at  a  time  to  prevent  chilling  and 
the  process  carried  forward  as  rapidly  as  possible  in  a  room  of 
not  less  than  75°  F.,  otherwise  it  is  best  omitted  in  the  very  small 
infants. 

As  infants  grow  older  they  may  be  dipped  in  or  sprayed  with 
water  heated  to  100°  F.,  and  this  may  be  gradually  lowered  to  95°  F. 


148  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

Under  no  circumstances  should  the  infant  be  bathed  without 
first  taking  the  temperature  of  the  water  and  the  room. 

Infants  with  subnormal  temperature  may  frequently  be  stimu- 
lated and  the  temperature  raised  by  placing  them  in  a  warm  bath 
which  is  held  between  103°  and  106°  F. 

In  cases  of  hyperpyrexia  a  bath  from  4°  to  5°  lower  than  the 
infant's  temperature  with  cold  to  the  head  is  of  therapeutic  value. 

In  the  presence  of  cyanotic  attacks  the  plain  warm  bath  or  weak 
mustard  bath  with  slight  friction  repeated  as  indicated  are  prob- 
ably the  best  therapeutic  measures.  During  such  attacks  the 
infant  should  be  handled  gently  as  not  infrequently  careless  and 
rough  handling  will  result  in  death  during  these  cyanotic  attacks. 

All  bathing  before  separation  of  the  cord  should  be  carried  out 
with  the  idea  of  promoting  surgical  cleanliness. 

Gentle  friction  and  light  massage  are  of  great  value  following 
the  bath.  Neither  of  these  methods  of  stimulating  the  circulation 
must  be  overdone.     Bathing  should  always  be  done  before  feeding. 

Care  of  the  Eyes.— If  properly  cared  for  at  the  time  of  delivery 
and  if  there  is  no  reaction  to  the  solutions  used  at  that  time,  they 
require  no  further  attention  except  ordinary  cleanliness.  The 
nurse  should  be  warned  against  getting  bath  water,  or  more  danger- 
ous, mustard  water  in  the  eyes.  In  cases  of  ophthalmia  the  treat- 
ment is  practically  that  as  used  for  full-term  infants  with  greater 
care  for  the  prevention  of  trauma  and  destruction  of  the  eye. 

The  Nose  and  Mouth.— Unless  there  is  a  direct  indication  due  to 
plugging  of  the  nose  or  an  infection  of  the  nose  and  mouth,  there 
should  be  no  manipulation  of  these  mucous  membranes,  because  of 
the  danger  of  abrading  them  and  opening  fresh  surfaces  for  infec- 
tion. In  the  presence  of  upper  respiratory  tract  infections  or 
stomatitis,  the  greatest  care  should  be  taken  in  applying  local 
treatment  as  advised  in  the  special  chapter  dealing  with  these 
diseases. 

The  use  of  the  nasal  catheter  is  always  a  dangerous  procedure 
and  even  the  passing  of  the  catheter  through  the  mouth  may  result 
in  trauma  if  not  carefully  performed. 

The  Breasts.  — In  simple  mastitis  the  breasts  should  be  anointed 
with  camphorated  oil  and  a  light  pad  of  cotton  held  in  place  by  a 
snug  breast  binder.  The  dressing  may  be  changed  every  second, 
third  or  fourth  day  as  indicated.  In  case  of  abscess  formation, 
which  is  of  very  infrequent  occurrence  in  prematures,  incision  and 
drainage  should  be  performed. 

The  Genitalia.— The  genitalia  more  especially  the  vulva  in  girls 
should  be  handled  with  extreme  care  in  order  to  avoid  trauma 
and  infection.  Small  cotton  combination  pads  should  be  applied 
to  the  buttocks  and  genital  organs  in  order  to  receive  the  feces  and 


DAILY  ROUTINE  149 

urine.  They  should  he  frequently  changed  in  order  to  avoid  irri- 
tation from  the  excreta.  By  the  use  of  these  small  pads  which  are 
described  under  the  chapter  on  clothing,  the  frequent  change  of 

diapers  can  he  avoided. 

When  there  is  evidence  of  infrequent  or  painful  urination,  which 
is  more  especially  true  in  a  male  infant,  it  should  be  immediately 
inspected  for  evidence  of  occlusion  due  to  the  drying  of  secretion 
or  exudate  in  the  presence  of  an  ulcer  at  the  meatus.  The  but- 
tocks are  easily  irritated  by  the  decomposing  urine  and  acid 
stools,  and  these  parts  readily  become  infected.  In  most  instances 
the  napkin  can  be  changed  without  removal  from  the  bed.  In 
the  treatment  of  all  lesions  about  the  genitalia  an  attempt  should 
be  made  to  keep  the  parts  dry  and  clean.  If  water  proves  irritat  ing 
a  starch  water  may  be  substituted  or  the  parts  may  be  cleansed 
with  benzoated  lard.  The  parts  are  then  dusted  with  stearate  of 
zinc  or  rice  starch.  When  these  simple  methods  fail,  a  1  per  cent 
mixture  of  balsam  of  Peru  in  castor  oil  or  lanolin  may  be  used.  ( )ur 
best  results  have  been  obtained  in  older  infants  when  the  buttocks 
are  exposed  to  warm  dry  air  through  the  medium  of  an  incandescent 
electric  light  or  sunlight  if  the  latter  is  possible  without  the 
danger  of  chilling  the  infant.  In  small  prematures  the  parts  may 
be  left  uncovered  in  the  heated  bed.  Small  rolls  of  cotton  ma}'  be 
used  to  separate  the  folds  of  the  skin. 

The  present-day  use  of  washing  powders,  which  are  retained  in 
improperly  rinsed  diapers  and  which  lead  to  a  rapid  decomposition 
of  the  urine,  may  be  a  source  of  intertrigo. 

Delayed  urination  is  not  infrequent  and  should  lead  to  an  inspec- 
tion of  the  genital  organs.  A  delay  of  twenty-four  hours  in  the 
passage  of  the  first  urine  is  quite  common  in  premature  infants. 
If  the  infant  is  otherwise  apparently  normal,  it  should  not  be  a 
cause  for  too  great  concern,  and  it  is  to  be  remembered  that  a  small 
quantity  of  colorless  urine  may  dry  out  and  go  unobserved.  The 
best  treatment  is  the  administration  of  fluids  approximating  one- 
twelfth  to  one-twentieth  of  the  body  weight  of  the  infant  during 
the  first  day  or  two,  and  later  approximating  one-sixth  of  the  body 
weight.  This  is  inclusive  of  all  fluids  administered.  A  warm 
moist  pad  over  the  lower  abdomen  and  pelvis  or  a  warm  bath  will 
frequently  cause  spontaneous  urination. 

Uric-acid  crystals  and  urates  are  very  commonly  found  in  the 
urine  of  the  premature  causing  a  pinkish  stain  on  the  napkin  and 
are  most  commonly  due  to  marked  concentration  of  the  urine.  At 
autopsy,  however,  more  frequently  than  in  the  full  term,  do  we  find 
these  salts  deposited  in  the  kidneys.  Considerable  pain  may  be 
caused  by  the  passage  of  these  deposits  through  the  ureter.  In 
every  case  fluids  should  be  pushed. 


150  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

The  Bowels. — The  anus  should  be  carefully  inspected  shortly  after 
birth  to  ascertain  the  presence  or  absence  of  anomalies.  Delay  in 
passing  the  first  stool  may  be  due  to  one  of  many  causes,  such  as 
delayed  peristalsis,  weak  abdominal  wall,  contracted  sphincter  and 
accumulation  of  feces,  most  commonly  in  the  sigmoid  or  cecum. 

We  believe  it  is  a  good  custom  to  attempt  to  promote  a  bowel 
movement  before  the  beginning  of  milk  feedings.  Frequently  the 
administration  of  inert  fluids  per  mouth  will  promote  peristalsis. 
We  do  not  hesitate  to  give  a  1-  or  2-ounce  normal  saline  colonic 
flushing.  The  amount  used  depends  upon  the  development  of 
the  infant.  A  small  glycerin  or  soap  suppository  answers.  If 
there  remains  doubt  as  to  the  patency  of  the  intestinal  tract,  a 
small  dose  of  castor  oil,  0.5  to  1  cc  (8  to  15  drops),  may  be  admin- 
istered per  mouth.  Once  the  patency  of  the  intestinal  tract  has 
been  established,  intestinal  evacuations  are  usually  spontaneous, 
more  especially  so  with  infants  fed  on  breast  milk  or  with  high 
carbohydrate  mixtures.     For  further  treatment  see  Constipation. 

Care  of  the  Skin.— The  skin  of  the  premature  is  very  delicate  and 
covered  with  lanugo  and  prominent  sebaceous  glands.  There  is 
a  great  tendency  for  the  skin  to  dry  and  crack  and  to  desquamate 
in  large  flakes.  This  is  especially  true  in  infants  suffering  from 
marked  jaundice.  There  is-  also  great  tendency  for  papular, 
vesicular  and  pustular  eruptions  of  various  types  to  develop. 
Erythematous  eruptions  are  of  frequent  occurrence.  All  of  these 
conditions  will  call  for  a  modification  of  the  daily  routine,  insofar 
as  the  baths  and  local  skin  care  are  concerned.  The  greatest 
danger  is  due  to  secondary  skin  infections  which  is  especially  true 
of  the  syphilitic  infant.  The  various  forms  of  dry  treatment  of 
these  lesions  offer  the  best  results  with  the  least  danger  of  spread- 
ing. The  application  of  silver  nitrate  to  each  pustule  and  vesicle 
after  cleansing  with  alcohol  have  given  us  the  best  results,  except 
in  the  case  of  syphilitic  infants  where  local  mercurial  treatment  is 
indicated. 

The  daily  care  of  the  skin  should  therefore  consist  of  the  avoid- 
ance of  trauma  and  exposure  to  secondary  infections  in  the  bathing 
and  handling  of  the  infant,  the  removal  of  all  excretions,  the  sepa- 
ration of  irritated  folds  by  a  layer  of  cotton,  and  the  dry  treatment 
of  all  non-suppurating  skin  lesions,  and  antiseptic  treatment, 
cauterization  or  specific  treatment  of  open  lesions. 

Delayed  Separation  of  the  Cord.— Delayed  separation  of  the  cord 
may  be  hastened  by  the  application  of  5  per  cent  silver  nitrate 
solution  or  50  per  cent  alcohol  dressings.  In  the  use  of  the  latter 
a  few  drops  of  alcohol  may  be  applied  to  the  dressing  at  regular 
intervals.  When  the  hard,  dry  cord  remains  intact  far  beyond  the 
usual  time  for  separation  it  may  be  necessary  to  cut  through  the 


DAILY  ROUTINE  151 

remaining  strands,  using  great  care  to  avoid  the  live  tissues.  Granu- 
lations are  best  treated  by  the  application  of  silver  nitrate  solution 
or  hard  stick. 

Body  Temperature.— The  body  temperature  must  be  taken 
through  the  rectum.  It  should  be  recorded  morning  and  evening. 
An  individual  thermometer  should  be  furnished  for  each  infant. 
Fluctuations  in  body  temperature  are  more  marked  than  in  the  full- 
term  infant  with  a  tendency  toward  hypothermia.  A  minimum  of 
97°  F.  should  be  considered  the  lowest  compatible  with  progress. 
Attempts  should  be  made  to  limit  the  daily  fluctuations  to  1.5°  F. 

Subnormal  temperature  may  result  from  undue  exposure  at  birth, 
subsequent  carelessness,  lack  of  development  of  the  nervous  system, 
absence  of  a  good  layer  of  subcutaneous  fat,  respiratory  insufficiency 
circulatory  weakness  and  insufficient  heat  production  due  to  lack 
of  food  or  defective  metabolism. 

These  etiological  factors  are  to  be  counteracted  by  definite  thera- 
peutic measures. 

Prevent  undue  exposure  and  trauma  from  the  moment  of  birth. 

The  infant  should  be  placed  in  a  heated  bed  of  proper  construc- 
tion and  kept  there  under  constant  supervision.  The  temperature 
of  the  heated  bed  should  be  varied  with  the  needs  of  the  individual 
infant.  Small  prematures  and  congenital  weaklings  with  marked 
hypothermia  should  temporarily  have  a  surrounding  temperature 
varying  from  85°  to  95°  F.  Older  and  stronger  infants  are  better 
placed  in  a  bed  at  75°  to  80°  F.  As  the  infant  develops  its  vital 
functions  and  the  subcutaneous  fat  increases,  the  temperature 
of  the  bed  should  be  gradually  lowered  to  that  of  the  nursery,  which 
should  be  kept  at  about  70°  to  75°  F.  It  should  be  the  rule  to 
regulate  the  temperature  of  the  heated  bed  by  the  rectal  temper- 
ature curve,  and  while  it  may  be  impossible  to  bring  the  body 
temperature  to  normal,  the  degree  of  hypothermia  is  our  best 
guide  in  the  application  of  external  heat. 

It  may  be  necessary  to  place  the  infant  in  a  hot  bath  to  raise 
the  temperature  and  stimulate  respiratory  and  cardiac  function 
following  syncope. 

Removal  from  the  bed  should  follow  definite  indications,  ordinary 
feeding,  changing  napkins  and  the  ordinary  routine  measures  can 
be  carried  out  in  the  bed. 

The  body  must  be  insulated  by  proper  clothing  to  be  described. 

The  body  fluids,  after  the  first  few  days,  must  be  maintained 
by  an  intake  of  from  one-sixth  to  one-eighth  of  the  body  weight  in 
fluids  in  twenty-four  hours,  and  this  must  include  a  caloric  intake 
of  more  than  a  sustaining  diet,  70  calories  per  kilo  after  the  first 
ten  days  of  life  (p.  ISO). 

Respiratory  and  circulatory  functions  must  be  protected  and  at 
times  stimulated. 


152  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

Hyperpyrexia  frequently  results  from  an  overheating  of  the  bed, 
and  when  a  high  temperature  is  noted  the  temperature  of  the 
bed  should  be  considered  as  a  possible  cause. 

Infections  of  all  kind  tend  to  the  development  of  fever,  but  on 
the  whole  the  reaction  is  le^s  than  in  the  full  term,  however,  the 
exception  may  be  true.  We  have  found  massive  pneumonias  at 
autopsy  which  were  unassociated  with  temperature  above  the 
average  normal. 

The  Pulse.— The  pulse  may  be  imperceptible  in  the  extremities 
and  require  auscultation  of  the  heart  for  timing.  The  cardiac 
action  will  usually  range  from  100  to  180  per  minute  in  the  small 
and  weak  infants,  although  occasionally  a  very  slow  pulse  is  noted, 
which  latter  usually  precludes  a  bad  prognosis.  The  best  indi- 
cator of  proper  cardiac  function  is  the  infant's  general  circulatory 
condition;  it  gives  far  more  information  than  the  number  of  heart 
beats. 

Respiration.— The  respirations  normally  vary  from  20  to  00  per 
minute  in  different  infants  and  are  to  a  large  extent  dependent  on 
the  heart  action  in  infants  not  suffering  from  atelectasis  or  central 
disturbances.  During  cyanotic  attacks  they  become  almost 
imperceptible  and  may  be  temporarily  suppressed.  Again  the 
general  condition  of  the  infant  is  the  best  guide. 

Weighing  should  be  done  at  a  specified  time  each  day  as  part  of 
the  general  routine,  with  a  good  scale.  The  infant  should,  unless 
contraindicated,  be  undressed  for  this  purpose,  and  this  is  best 
done  before  the  bath.  The  relation  between  the  time  of  the  last 
feeding  and  passing  of  feces  should  be  noted. 

In  older  well  infants  daily  weighing  may  not  be  indicated  but 
in  prematures  it  should  be  done  as  a  routine,  more  especially  in 
difficult  feeding  cases.  Those  fed  at  the  breast  must  be  weighed 
before  and  after  nursing,  and  the  food  taken  is  to  be  recorded. 

Loss  of  Body  Weight  during  the  First  Days  of  Life.— This  occurs 
almost  constantly  in  premature  infants,  the  percentage  loss  being 
greater  in  the  premature  than  in  the  full-term  infant,  and,  on  the 
whole,  they  are  much  slower  in  regaining  their  birth  weight.  In 
the  group  of  cases  studied  by  the  author  the  average  loss  in  the  cases 
weighing  between  1000  and  2000  gm.  was  10.9  per  cent.  More 
recently  we  have  been  able  to  reduce  the  initial  loss  to  approximately 
5  per  cent  in  a  number  of  cases  by  carefully  increasing  the  fluid 
intake  after  the  first  twelve  hours. 

Most  of  our  cases  have  regained  their  birth  weight  by  the 
eighteenth  to  the  twenty-first  day,  with  a  daily  gain  averaging  from 
12  to  40  gm.  after  reaching  their  lowest  weight,  which  is  usually 
about  the  fifth  day.  Infants  under  1500  gm.  may  be  considered 
as  progressing  satisfactorily  on  an  average  of  from  10  to  20  gm., 


DAILY  ROUTINE  153 

and  doubling  their  birth  weight  in  seventy-five  to  one  hundred  days; 
and  those  from  1500  to  2000  gm.  when  they  are  making  a  daily 
gain  of  from  15  to  25  gm.  after  they  have  reached  or  passed  their 
birth  weight  with  a  doubling  of  that  weight  in  from  fifty  to  one 
hundred  days. 

The  Infant's  Clothes.— The  wardrobe  should  be  planned  and 
completed  in  advance  of  labor.  In  emergencies  this  may  not  be 
possible.  It  is  imperative  to  remember  that  preservation  of  the 
body  heat  must  be  begun  immediately  after  birth;  on  the  con- 
finement bed  itself.  Insulation  of  the  body  is  the  prime  thought  to 
be  borne  in  mind  when  planning  the  wardrobe.  The  clothes  must 
fit  the  body  snugly,  providing  only  for  a  thin  layer  of  air  between 
the  body  and  the  dress.  The  material  must  be  selected  with 
some  knowledge  of  the  method  by  which  external  heat  is  to  be 
supplied.  The  head,  except  the  face,  and  the  extremities  must  be 
equally  protected  with  the  body. 

At  birth  the  infant  is  received  into  a  warm  blanket  and  imme- 
diately placed  in  a  heated  basket,  heated  bed  or  incubator. 

In  supplying  external  heat  it  should  be  remembered  that  these 
infants  are  easily  burned,  and  such  burns  are  usually  fatal. 

In  small  prematures  for  temporary  emergency  use  a  sterile 
cotton-pack  which  completely  envelopes  the  infant,  except  for  the 
face  and  genito-anal  region,  may  be  applied.  It  should,  however, 
be  remembered  that  cotton  is  far  inferior  to  wool  in  prevention  of 
heat  radiation.  An  improvised  jacket,  preferably  of  flannel,  may 
be  placed  on  the  outside  of  the  cotton  to  hold  it  in  place. 

To  the  genital  region  and  anus  an  easily  changed  small  pad  of 
cotton  or  gauze  combination  may  be  applied.  Whenever  the  infant 
becomes  soiled,  it  is  only  necessary  to  change  the  pad.  This  should 
not  be  neglected. 

If  special  outer  garments  are  not  available,  the  infant  should 
at  once  be  wrapped  in  a  small  heavy  woolen  blanket,  or  cotton 
combination,  which  can  be  fastened  about  the  body  loosely  by 
bandages  or  safety-pins  in  papoose  fashion.  The  greatest  dis- 
advantage of  such  a  dress  is  the  limitation  of  body  movements, 
which  is  of  considerable  importance  even  in  these  infants.  All 
pressure  and  constriction  must  be  avoided  (Figs.  75,  70  and  7"  I. 

In  a  well-equipped  station  several  sets  of  special  cloths  should  be 
provided.  These  should  be  kept  sterilized  in  packets.  The  outfits 
will  differ  somewhat,  depending  upon  whether  the  open  or  closed 
incubator  beds  are  used. 

With  the  open  type  of  heated  beds,  all  garments  next  to  the  body, 
except  the  napkins,  should  be  made  of  light-weight  flannel. 

A  set  of  clothing  should  consist  of  woolen  bands  of  small  size; 
small  woolen  undershirts;  overshirts;  pinning  skirts;  woolen  stock- 


154 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


ings;  diapers;  pads;  bibs;  and  a  woolen  bag,  with  an  attached 
head-piece,  with  a  slit  over  the  upper  part  in  front  to  allow  passing 
over  the  head.  The  bag  should  be  open  at  the  bottom  to  allow  of 
its  being  raised  for  changing  of  napkins,  dressing  the  cord  and 
general  care  of  the  infant  (Fig.  77).  The  overshirt  should  be  some- 
what longer  and  larger  than  the  undershirt  and  may  to  very  good 


Fig.  77. — Woolen  bag  with  hood.     For  further  protection  it  may  be  drawn  together 
beneath  the  infant's  chin. 


advantage  be  made  from  French  pique  which  is  less  impervious  to 
air  than  flannel. 

In  the  absence  of  a  sleeping  bag  the  infant  may  be  wrapped 
in  a  light  flannel  blanket,  so  applied  that  the  upper  part  will  form 
a  hood. 

With  the  closed  type  of  bed,  the  sleeping  bag  and  blanket  are 
unnecessary. 


DAILY  ROUTIXK 


l.v, 


A  complete  outfit  for  use  with  an  open  bed  should  contain: 

Four  bands  12  inches  long  and  4  inches  wide  (flannel  or  knit 
wool). 

Four  undershirts  with  blind  sleeves  and  draw  string  at  neck 
(flannel). 

Four  overshirts  (flannel  or  French  pique  fleeced). 


Fiu.  7S. — Wool  flannel  undershirt  with 


Fig.   79. — Heavy  overshirt  made  from  French  pique. 


Four  pinning  skirts  (French  pique  24  by  2S  inches). 

Two  bags  with  hoods  30  inches  long  and  20  inches  wide  (woolen). 

Or  two  blankets  1  yard  square  (flannel,  knit  wool  or  cashmere). 

Four  pairs  of  stockings  (woolen). 

Two  dozen  diapers  size  18  by  20  inches  (fine  bird's  eye). 

Small  genital  pads  (absorbent  cotton  and  gauze). 

Bibs  (same  material  as  jackets). 


156 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


How  to  Dress  the  Baby.— The  clothes  must  be  put  on  quickly  with- 
out undue  exposure.     First,  the  abdominal  band  is  applied,  if  needed 


Fig.  80. — Pinning  skirt  or  blanket  for  the  lower  half  of  the  body. 

French  pique.) 


(Made  from 


Fig.  81.— Bib. 


to  retain  cord  dressing,  otherwise  it  may  be  omitted,  then  the  under- 
shirt, followed  by  the  overshirt,  both  of  which  are  pinned  at  the  side, 
next  the  small  genital  pads  and  diapers,  to  be  followed  by  the 


DAILY  ROUTINE 


157 


pinning  blanket,  the  latter  being  turned  up  over  the  feet  and  pinned 
at  the  back. 

The  infant  may  then  be  placed  directly  in  its  bed  and  its  head 
and  body  covered  by  a  blanket,  or  it  may  be  put  in  one  of  the 
woolen  bags  before  being  put  in  its  bed.  The  selection  of  the  last 
article  of  dress  will  depend  largely  on  the  condition  of  the  infant. 


Fig.  82.— Pattern  for  designing  under-  and  overshirts.     Diagram  of  body  and  sleeve 

patterns. 


The  essentials  of  the  dress  are: 

1.  Good  insulation. 

2.  Cleanliness. 

3.  Protection  from  changes  in  temperature. 

4.  Ease  of  application  and  removal  with  a  minimum  manipula- 
tion of  the  infant. 


158 


CARE  AND  NURSING  OF  PREMATURE  INFANTS 


In  the  emergency  and  in  very  small  and  weakly  infants  these 
indications  may  be  met  temporarily  by  a  complete  envelopment  in 
cotton,  but  as  soon  as  safe  and  convenient  the  infant  should  be 
dressed  in  the  simple  and  easily  applied  garments  described.     These 


Fig.  83. — Dressing  the  baby.     Under-  and  overshirts  applied. 

garments  are  so  applied  that  they  may  be  described  as  upper  and 
lower  garments.  For  the  changing  of  soiled  napkins  the  upper 
half  of  the  clothes  need  not  be  removed.  Complete  undressing  is 
required  only  for  the  purpose  of  bathing. 


Fig.  S4. — Dressing  the  baby.     Under-  and  overshirts  and  pinning  shirt  applied. 


Many  of  these  little  infants  vomit  repeatedly  and  if  it  were  not 
for  the  heavy  texture  of  bib  and  jacket,  it  would  necessitate  very 
frequent  complete  undressing  of  the  infant,  instead  of  removal 
of  the  soiled  linen  only,  which  is  but  part  of  his  dress.  These 
clothes  are  easily  ironed.     Absorbent  cotton  can  be  used  as  a  bib. 

We  also  provide  for  fresh  bedding  preferably  by  the  use  of 
untarred  jute  in  our  bed  and  pillows,  if  the  latter  are  used,  which 
can  be  thrown  away  at  will  because  of  its  cheapness. 

The  infants  should  be  watched  very  closely  and  the  wet  and 


DAILY  ROUTINE  159 

soiled  linen  changed  immediately  to  prevent  intertrigo,  as  the  urine 
dries  very  quickly  in  the  heated  bed  and  when  concentrated  erodes 
the  skin,  which  is  severe  and  disastrous  to  these  children.  After 
each  change  the  infant  should  be  carefully  cleansed,  either  with 
water,  benzoated  lard  or  mineral  oil,  before  being  replaced  in  the 
heated  bed.  The  clothes  should  fit  snugly  and  are  to  be  preheated 
before  applying  and  must  be  absolutely  dry.  This  especially  applies 
to  diapers.  In  laundering  the  baby's  clothes  no  bluing,  lye  or  strong 
alkaline  soaps  should  be  used,  the  best  for  this  purpose  being  a 
neutral  or  nearly  neutral  soap  of  the  type  of  which  Ivory  soap  is  an 
example.  The  clothes  should  then  be  rinsed  in  pure  water  before 
drying. 

The  child  should  not  be  wiped  with  the  soiled  diaper,  but  with 
absorbent  cotton  which  can  then  be  destroyed.  The  same  should 
apply  for  bathing  purposes,  where  cotton  is  far  more  cleanly  than 
a  sponge. 

Arranging  the  articles  on  and  in  a  heated  dressing  table  expedites 
dressing  the  infants  with  the  above  style  of  dress.  The  child  can 
be  dressed  in  one  or  two  minutes  without  undue  manipulation. 

Watch  for  Sickness.— The  possibility  of  grave  pathological  changes 
with  minor  clinical  manifestations  must  be  constantly  borne  in 
mind  in  the  care  of  prematures.  In  order  to  diagnose  and  properly 
counteract  the  dangers  which  may  follow  the  overlooked  simple 
ailments,  at  least  one  daily  general  inspection  and  examination, 
quickly  but  carefully  performed,  is  required.  The  exception  to 
this  rule  is  the  immediate  danger  due  to  handling  extremely  delicate 
infants. 

In  no  other  group  of  infants  is  a  careful  study  of  the  individual 
functioning  of  the  heat  centers  and  the  respiratory,  circulatory, 
nervous,  genito-urinary  and  gastro-intestinal  organs  so  imperative. 

The  Hospital  Records.— The  records  should  include  the  following 
forms: 

1.  A  history  and  physical  examination  blank  (Fig.  85). 

2.  A  graphic  record  chart  (Fig.  86). 

3.  A  special  feeding  card  for  recording  the  amount  of  individual 
feedings  and  stamped  by  the  time  clock.  Time  of  urination  and 
stools  and  a  description  of  the  latter  can  be  recorded  on  this  same 
card.  Inspection  of  the  infant  at  feeding  times  will  prevent  neglect 
in  changing  the  infant  and  assist  in  the  prevention  of  local  and 
ascending  bladder  infections.  The  data  from  the  feeding  card 
should  be  transposed  to  the  graphic  record  sheet  daily  (Fig.  87). 

4.  Temperature  chart  for  room  and  bed.  On  this  sheet  is 
recorded  the  temperature  of  the  bed  in  which  the  baby  is  kept. 
It  should  be  charted  at  six-hour  intervals,  best  at  6  a.m.,  12  M.  and 
6  and  12  p.m.     These  are  the  most  likely  times  for  maximum  changes 


160         CARE  OF  NURSING  AND  PREMATURE  INFANTS 

in  the  ward  temperature  which  might  call  for  an  increase  or  decrease 
in  the  external  heat  to  be  applied  to  meet  the  desired  bed  tempera- 
ture. At  the  same  time  the  ward  temperature  should  be  recorded 
and  the  humidity  in  the  room  and  bed  should  be  noted  and  recorded 
(Fig.  88).  _ 

5.  Physician's  order  blank  (Fig.  89). 

6.  Milk  station  order  blank  (Fig.  90). 

7.  Wet-nurse's  record  blank  (Fig.  91). 

The  Clinical  Record.— A  careful  history  is  most  important,  as 
much  evidence  which  Avill  have  a  direct  bearing  on  the  prognosis 
will  frequently  be  elicited  as  well  as  suggestions  for  feeding  and 
therapy.  The  maternal  history  as  to  illness,  previous  pregnancies 
and  their  outcome  must  be  elicited.  The  paternal  history  is  also 
of  prime  importance.  The  presence  or  absence  of  acute  illness  in 
the  home,  more  especially  whooping-cough,  scarlet  fever,  diphtheria 
and  septic  infections  should  be  investigated  before  the  infant  is 
discharged. 

Every  hospital  record  should  show  the  data  of  at  least  two  social- 
service  investigations.  This,  while  usually  neglected,  frequently 
reveals  conditions  in  the  home  which  make  the  early  discharge  of 
these  retarded  infants  impossible,  if  their  lives  are  to  be  conserved. 

The  first  investigation  should  be  made  in  the  shortest  time 
possible  after  the  infant  enters  the  hospital,  the  last  just  previous 
to  the  infant's  discharge. 

Conserving  the  Mother's  Breasts.  — If  the  mother  does  not  accom- 
pany the  infant  she  should  be  encouraged  to  conserve  her  breast 
milk.  This  may  be  accomplished  by  one  of  several  methods: 
(1)  By  expression  at  regular  intervals,  and  if  this  is  the  method 
used  she  should  be  encouraged  to  send  her  milk  to  the  hospital 
once  or  twice  daily,  if  for  no  other  reason  than  to  keep  a  record 
of  her  faithfulness.  (2)  By  nursing  a  neighbor  baby,  one  loaned 
to  her  from  the  hospital  or  some  other  source.  Later  by  having 
her  come  to  the  institution  to  nurse  her  own  or  a  full-term  hospital 
baby.  (3)  By  placing  a  puppy  to  her  breasts.  While  this  latter 
at  first  thought  may  seem  repulsive,  it  has  in  our  own  experience 
proved  to  be  a  most  desirable  expedient. 

REQUIREMENTS  FOR  THE  CARE  OF  PREMATURE  INFANTS 
IN  THE  HOME. 

The  establishment  and  maintainance  of  properly  equipped 
hospital  stations  are  essential  to  the  lowering  of  mortality,  more 
especially  in  the  large  cities  and  particularly  among  the  poorer 
classes.  A  careful  consideration  of  the  requirements  for  and 
results  to  be  expected  from  their  care  in  the  home  is  equally  essential. 


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Cyanosis 

Hemorrhages 

Stridor 

Rhinitis 

Icterus 

Convulsions  (Early,  Late) 

Difficult  Nursing 


\ itii.n 

Meleorism 

Diarrhea 

( loQstipation 

Atelectasis 

Bronchitis 

Pneumonia 

Edpma 


Cerebral  Hemorrhages 

Encephalitis 

Adenitis 

Otitis 

Cord  (Condition  of) 

Pyelitis 

Rachitis 

Mr-gaecphalus 

Spasmophilia 

Hydrocephalus 

Anemia 

Meningitis 

Scurvy 

SOf)- 


Conitgenol  Deformities 
l  Iperations 


Important  details  of  diseases. 


-During  first  week- 


First  ten  days  (Breast,  bottle, 
Amount 


Subsequent  feedings.     Kind- 
Interval 


;ed).     Number- 


Administered    (Breast,  dropper,  bottle,  catheter). 
Method 


Present  Feeding  (Able  t 


MOTHER'S  general  health: 

Quality  of   breasts  (good,  fair,  poor) 

Is  she  pumping,  expressing,  olln-r  inHln,.|- 

Why  was  nursing  discontinued? 

Does  the  baby  take  all  of  its  feedings? 

Does  the  baby  vomit?. . How  1 

Does  the  baby  have  colic? Whc 

How  many  times  a  day  do  the  bowels  move 
Color 


Is  she  available?     (Ye 

Xipiilc  mood,  bad,  inverted)  — 


PHYSICAL  EXAMINATION 
.     . . —Respiration.      (Underlii 


INSPECTION:     Bright  Apathetic 

GENERAL  CONDITION:     Fat  Tli 

SKIN: 

Normal  Prickly  Heat 

Tissue  turgor  Seborrhea 

MUSCLES:     Biceps  and  thighs 

HEAD :  Normal  Deformities 

i  'raniotabes _ . Megacep 

EYES:     Pupils  equal,  unequal 

Blepharitis 

NARES:  Clear     Crusted     Discharge     Chara 

MOUTH :  Normal 

Deformities,  hare-lip,  cleft  palate,  et 


■  each  word  describing  condition) 
Fair  Poor 


-jStomatitis  (type)— 


PREMATURE  INFANTS 
Date 


I 

Telephone  _     . 
Guardian's  Na 

i;.  fi  i  red  i  o 


House     Flat     Front     Roar     Floor. 


WHY  IS  INFANT  BROUGHT  TO  THE  HOSPITAL?     (Mother's 


in  hospital.  homc„ 


Method  by  which  l»>dy  t  nn|  ..i  ;M  ui  .■  lei-  lnrn  maintained— 


HISTORY  OF  PREGNANCY     dm^t.  duration  ami  [.rounds  of  illnesses, 


L&sl  Menstruation  (first  day  of) 

HISTORY  OF  LABOR  (Length)- 


-hours,  Spontaneous,  Indued,  i  >)„,■,  1 1\  .. 


FAMILY  HISTORY 


Living        Dead  Age  Condition  of  Health  Caiis.-ui   I  ><..,>  I, 


Order  of  Pree,ji:tinie> 


PERSONAL  HISTORY 

! i  birth 

( londition  at  birth 


Single,  Tw  ins,  Triplets  1 1  Irder  oi  bii  I 


sight  of  each  and  number  i 


Calculated  Fetal  Age.     By  History- 
Bj   Radiograms 


ind  Abnormalitit 


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PHYSICAL  EXAMINATION       Continued  i 


TONGUE : 
THROAT : 
GLANDS : 

EARS: 
NECK: 

CHEST: 
LUNGS: 


Moist,  dry,  injected 

Normal,  injected,  membrane  (type) 
Normal  Enlarged 

Others. 


I  !'H ti  :ir.  Intniinul 


a!     1 

— * 

„,„, 

left. 

Dis 

terse 

ight, 

,(i     r-liir'.ctir 

barrel  flat  funnel  pigeon  rosar? 

n->j.irriti(iti  isj.Mi]it:,[R'oU8,  induced).     Degree  "i  asphyxia 

s Respiration   (thoracic,  abdominal).     Evideno    i>f  an  k'i'ta 


i  to  left  of  mid-sternal  line, 
i  to  right  of  mid-sternal  line. 
ti  space  in  mid-clavicular  line. 
1  outside,  inside,  raid-clavicular  lit 


Aotion;     Numl  ■<  i  . 

—    reguli" 

irregular 

.Sounds : 

Clear 

impure 

Rlnr.rt.priJssi.ro 

LIVER: 
SPLEEN : 
KIDNEYS : 
GENITALS : 


FEET: 
SPINE: 
REFLEXES : 


Hernia  umbilical 

Cord  (condition  of) 

Palpable  Enlarged 

Palpable  Yea     No    Sis 


Hydros  lo  lit.     I-i. 


1  lefoi Mm i-  - 

Normal 

Patellar 

Kernig 

Birth 

Doubled 

pine  to  ■■ '  rtex 
l  fOeal  ion  i  entei  ol  bodj 
Date 


ndarii's  in  Mid.  <  '1,  L. 


Circumcised  Undescended  testicle  Kt. 

Vaginitis  Anus rmal,  al i 1} 

Deformity  (acquired,  congenital)-         Fra 

Rickets 

Acquired  Congenital 

Deformities 

Brudsinski  Oppenheim  1 

Babinski  ( 'hvostek 


CIRCUMFERENCE:      I l.-.t, I  mi  ri|.it.i-fn,i,iah- 


RECOMMENDATIONS : 
FEEDING  


i:\TKH\AL  HEAT- 


SUMMARY  OF  HISTORY  AND  EXAMINATION: 

Father's  History 

Mother's  History.     Para 


Patlmtogy  r,f  Pregnancy 

Patli"l"L'>    nf  lalicir.      Length— 


-hours.    Character 


Infant..      Simile,  Twins,  Triple 

Length  of  gestation 

Temperature  when  rece 


Congenital  disease  (Luesi  i  Kvitl.-n.-.- i_ 
Other - __ . _ 


Congenital  deformities— 
Birth  injuries 


Post  natal  diseases.     First  week- 
Previous  care,     i  Artificial  heat,  c 

Previous  reeding.     Kind 

Birth  weight ! 


.days,     Age  when  receivec 
"P.     Condition  when  t 


_lni(ial  lnss  of  wi'i«ht_ 


Age  when  B.  W.  regained— 
Anemia 


-Age  when  B.  W,  doubled— 
Spasmophilia 


Other  pathological  findings— 


i  i.lisi-harge.     Age,  etc.. 


A|i|i:in  ill  eanse  of  Prematurity- 
Cross  Index 


Future  Development  [Mental,  Physical) 


V    M 


&     m 


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LABORATORY  AND   SPECIAL  EXAMINATIONS 


_Di  acetic  Acid— 


RADIOGRAM:     Skek-tmi.  Clu-st,  Digestive  Truel   I  Fur  Aur,  ilrf.irmity,  infection). 


BLOOD:      Date- 


._( 'ejaculation  Tinie_ 


B 
B. 

V    inal  Smea 

S  inal  Puncti 

Electrical  Ren' 


First  Visit,  Date 


Mother's  attitude— 

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HOSPITAL  RECORDS 
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CARE  AND  NURSING  OF  PREMATURE  INFANTS 


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164        CARE  AND  NURSING  OF  PREMATURE  INFANTS 


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Fig.  91. — Wet-nurse  milk  supply  record  sheet. 


166  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

In  many  instances  the  premature  is  born  unexpectedly  with  little 
time  for  preparation  for  its  reception.  The  expectancy  of  a  pre- 
mature labor  is  almost  always  associated  with  more  or  less  excite- 
ment in  which  thought  for  the  baby's  needs  are  likely  to  be  over- 
looked, the  mother  usually  being  given  first  consideration. 

It  will,  therefore,  be  our  object  to  outline  a  proper  routine  for 
the  establishment  of  an  emergency  home  unit. 

In  the  home  care  of  these  infants  the  same  rules  for  hygienic 
maintainance  of  body  temperatures,  breast  feeding,  and  daily  routine 
must  be  maintained  as  suggested  for  their  hospital  care. 


Fig.  92. — Special  bath  room  equipment  for  private  home,  showing  dressing  table 
(padded)  with  drawers,  built  over  radiator.  Shelves  for  dressing,  etc.,  above  the 
table.     Bathing  board  over  one  end  of  bath  tub. 

The  Nursery  Unit.— Whenever  possible  two  rooms  should  be  set 
aside  for  the  infant's  use;  one  equipped  as  a  nursery  with  furnish- 
ings similar  to  those  described  for  the  hospital  nursery.  The  second 
room  is  to  be  used  for  sleeping  quarters  and  must  be  equipped  with 


REQUIREMENTS  FOR  CARE  OF  PREMATURE  INFANTS     167 

a  heated  bed.  These  rooms  must  be  well  ventilated  and  at  the  same 
time  well  heated.  In  both  these  rooms  all  draperies  and  unnecessary 
furniture  must  be  removed. 


Fig.  93. — Plan  for  arrangement  of  stations  in  a  private  home,  consisting  of  one 
large,  well  ventilated  and  heated  room  and  a  bath  room. 

A  bath  room  properly  equipped  (Fig.  92)  makes  a  splendid  second 
room  in  which  the  general  care  of  the  infant  can  be  administered. 


168  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

This  room  should  be  given  over  to  the  exclusive  use  of  the  infant. 
When  such  a  bath  room  is  available  only  one  other  room  is 
needed. 

While  the  baby  is  being  dressed  or  bathed  the  nursery  or  bath- 
room temperature  should  be  in  the  neighborhood  of  80°  F.  A  gas 
or  electric  stove  will  be  of  assistance  in  accomplishing  this.  When 
a  superheated  bed  is  in  use  the  sleeping  room  may  be  kept  between 
70  to  75°  F.  These  rooms  should  be  devoid  of  all  excessive  furniture 
and  draperies.  All  visitors  other  than  the  attendants  and  physician 
must  be  excluded. 

The  equipment  of  the  room  or  rooms  should  include  a  heated  bed, 
a  dressing  table,  preferably  heated,  or  placed  over  a  warm  radiator, 
a  small  electric  or  gas  stove  for  emergency  use,  a  scale,  bathing  and 
feeding  utensils,  a  thermometer,  a  hvgrometer  and  surgical  supplies 
(Fig.  93). 

The  Superheated  Bed.— In  the  home  hot-water  bottles,  a  properly 
protected  electric  pad  or  an  improvised  incubator  will  answer  the 
purpose  (p.  223). 

A  thermometer  should  be  placed  alongside  the  baby  as  too  great 
emphasis  cannot  be  laid  on  the  dangers  and  fatalities  due  to  over- 
heating and  burning  of  prematures.  There  is  a  great  tendency  to 
hyperthermia  which  must  be  recognized  and  properly  interpreted. 
There  is  usually  a  rapid  return  to  the  normal  body  temperature 
without  bad  effects  upon  removal  of  the  cause  unless  too  long 
continued.  The  general  care  of  the  heated  bed  has  been  described 
on  p.  218. 

The  Nurse.— She  must  be  experienced  in  the  feeding  and  handling 
of  such  infants  and  must  be  tireless  in  her  efforts  to  prevent  compli- 
cations. She  must  be  diplomatic  in  order  to  permit  the  overcoming 
of  the  mother's  anxiety,  with  its  consequent  effect  upon  her  milk 
secretion.  She  must  be  able  to  control  the  habits  of  the  wet-nurse, 
if  one  is  employed.  She  must  insist  upon  taking  orders  from  the 
physician  and  no  one  else.  She  must  be  able  to  keep  a  careful 
record,  practise  aseptic  nursing,  avoid  accidents  and  be  cleanly  in 
her  personal  habits. 

A  second  person  should  be  present,  who  can  assist  and  relieve 
the  nurse.  She  must  be  willing  to  work  under  the  nurse's  supervi- 
sion. Such  a  person  is  indispensable  in  the  presence  of  emergency. 
Only  those  directly  interested  in  the  care  of  the  baby  should  come 
in  contact  with  it. 

The  Infant's  Food.— Breast  milk  should  be  considered  indispen- 
sable and  during  the  first  days  of  life  it  may  be  necessary  to  obtain 
a  temporary  supply  from  a  neighboring  mother,  a  wet-nurse  or  a 
hospital.    A  small  amount,  90  to  240  cc  daily  will  usually  meet 


REQUIREMENTS  FOR  CARE  OF  PREMATURE  INFANTS     1G9 

the  emergency.  Only  when  these  sources  of  supply  fail  absolutely 
should  artificial  feeding  be  instituted. 

Preparation  for  Labor.— The  protection  of  the  infant  must  begin 
with  the  first  stage  of  labor.  The  room,  receiving  clothes  and  its 
bed  must  be  properly  warmed.  Refrigeration  is  the  direct  cause 
of  more  deaths  among  prematures  than  any  other  extraneous  factor. 
All  routine  measures  described  for  the  hospital  care  in  Chapter  Vll 
should  be,  so  far  as  possible,  observed  in  the  home. 

Clothes.— The  clothes  best  suited  have  been  described.  Simplicity 
in  dress  with  a  minimum  manipulation  or  changing  being  the  object 
to  be  attained,  because  of  the  dangers  of  exposure,  trauma  and 
infection.  The  infant  should  be  received  into  warm  blankets. 
One  of  the  most  common  errors  is  to  allow  the  infant  to  remain  in 
such  a  loosely  applied  robe,  which  does  not  provide  for  proper 
insulation  of  the  skin  because  of  the  large  air  space  between  the 
blanket  and  the  infant.  This  allows  rapid  radiation  of  the  body 
heat.  Therefore,  at  the  earliest  possible  moment  the  infant  should 
be  protected  from  head  to  foot  by  closely  applied  warm  clothes. 
The  body,  if  woolen  clothing  is  not  at  hand,  should  be  wrapped  in 
cotton.  The  cotton  should  be  applied  in  two  parts,  the  upper 
half  encircling  the  head  except  the  face,  together  with  the  trunk 
and  upper  extremities,  the  lower  half  should  encircle  the  lower 
extremities,  a  small  pad  being  applied  to  the  genitalia  and  buttocks. 
This  allows  for  cleansing  the  genital  region  with  a  minimum  of 
manipulation.  The  upper  part  of  the  body  may  then  be  covered 
by  a  small-sized  infant's  shirt  on  the  outside  of  the  cotton  jacket 
and  the  infant  is  then  wrapped  in  a  woolen  blanket  in  its  bed.  The 
clothes  best  adapted  for  later  use  can  be  made  according  to  the 
description  on  page  155,  and  should  be  supplied  as  soon  as  possible. 
A  woolen  blanket  should  cover  about  three-quarters  of  the  basket, 
the  head  being  left  open. 

The  Bath.— The  advisability  of  giving  a  warm  bath  has  been  dis- 
cussed but  it  is  our  desire  to  emphasize  the  conclusion  that  the 
initial  bath  is  to  be  omitted  whenever  there  is  danger  of  unduly 
exposing  the  infant.  In  a  proper  environment  the  warm  cleansing 
bath  should  be  given  in  the  absence  of  cardiac  and  respiratory 
complications. 

Further  Early  Care.— The  baby  must,  under  all  circumstances,  be 
under  constant  observation  during  its  first  hours  because  of  the 
dangers  of  cardiac  and  respiratory  complications,  over-  and  under- 
heating,  overcovering,  and  overlying,  the  latter  due  to  careless 
placing  of  the  infant  in  the  bed.  Whenever  feasible  the  infant 
should  be  placed  in  a  properly  prepared  room  away  from  the  mother. 
Its  personal  attendant,  other  than  for  special  care,  need  not  neces- 


170  CARE  AND  NURSING  OF  PREMATURE  INFANTS 

sarily  be  a  trained  one.  When  a  dependable  person  is  not  at  hand  it 
should  be  kept  in  the  room  with  the  mother. 

The  general  care  should  be  that  as  described  for  hospital  care. 

The  Results  Obtained.— With  human  milk,  a  skilled  nurse,  an 
adequate  bed,  a  good  nursery  and  proper  feeding  and  nursing 
technic  the  same  good  results  are  to  be  expected  as  in  hospital  care. 

Transportation  to  a  Hospital.— Removal  to  a  hospital  station  should 
not  be  delayed  when  nursing  and  feeding  needs  cannot  be  fulfilled 
in  the  home.  It  should  be  moved  in  a  specially  prepared  bed  so 
that  it  will  not  be  exposed  en  route.  When  the  infant  is  to  be  sent 
to  the  hospital  which  is  provided  with  a  transportation  incubator, 
the  institution  should  be  called  upon  to  transfer  the  infant. 


CHAPTER  VIII. 

METHODS  OF  FEEDING. 

It  is  necessary  to  consider  these  infants  as  belonging  to  two  large 
groups: 

1.  Those  able  to  nurse  at  the  breast. 

2.  Those  too  weak  to  nurse  at  the  breast. 

INFANTS  NURSING  AT  THE  BREAST. 

This  presupposes  that  the  infant  has  the  proper  physical  develop- 
ment to  withdraw  milk  from  the  human  breast  in  the  presence  of 
an  abundant  supply  and  well-developed  nipples.  Such  an  infant 
may  be  placed  at  the  breast  two  or  three  times  during  the  last  half 
of  the  first  day  after  the  circulatory  and  respiratory  functions  are 
well  established.  Following  the  first  day  it  should  be  placed  at 
the  mother's  breast  regularly  for  two-  or  three-minute  periods  at 
three-  or  four-hour  intervals,  even  though  the  breast  contains  little 
milk.  Following  these  attempts  at  nursing,  food  should  be  supplied 
from  another  mother  or  a  wet-nurse,  whenever  such  a  supply  is 
obtainable  rather  than  to  institute  artificial  feeding.  In  the 
hospital  it  is  our  custom  to  give  these  additional  feedings  by  hand; 
in  private  practice  the  infant  may  be  placed  to  the  wet-nurse's 
breast,  one  of  the  breasts  being  set  aside  for  this  purpose,  and  if 
there  is  a  difference  in  the  breasts  the  better  one  is  selected  for  the 
premature.  Whenever  possible  this  is  the  best  method  of  getting 
the  food  to  the  baby,  as  it  prevents  contamination  of  the  milk, 
stimulates  the  breasts  and  develops  the  baby's  independence  as  well 
as  his  sucking  muscles.  However,  it  is  to  be  remembered  that 
congenital  syphilis  is  to  be  excluded,  both  in  the  infant  and  wet- 
nurse,  in  all  cases  where  the  infant  is  put  directly  to  a  breast  other 
than  the  mother's.  Not  infrequently  great  assistance  may  be  given 
the  infant  in  securing  its  milk  by  one  of  two  methods:  Either  by 
expressing  the  milk  directly  into  the  baby's  mouth  or  by  placing 
the  wet-nurse's  baby  on  the  opposite  breast  (Fig.  94)  which  reflexly 
stimulates  the  flow  of  milk  into  the  opposite  breast,  thereby  assist- 
ing the  weak  infant  in  obtaining  its  food.  Overfeeding  becomes  a 
danger  in  this  direct  application  of  the  infant  to  the  breast,  and 
weighing  before  and  after  nursing  should  be  practised.  Under- 
feeding is  an  even  greater  danger,  and  here  again  the  infant  must 


172 


METHODS  OF  FEEDING 


be  weighed  before  and  after  feeding  to  ascertain  the  amount  of  food 
taken.     If  insufficient,  further  food  can  be  supplied  by  hand  feeding. 


Fig.  94. — Feeding  premature  infant  by  direct  expression  from  right  breast.     Wet 
nurse's  baby  on  left  breast  assists  in  stimulating  the  flow  of  milk  into  the  right  breast. 


INFANTS  TOO  WEAK  TO  NURSE  AT  THE  BREAST. 


In  this  group  of  infants  careless  exposure  must  be  avoided.  In 
the  absence  of  cyanosing  they  may  be  fed  without  removal  from  the 
bed.  If  cyanosis  threatens  they  should  be  fed  on  the  dressing  table. 
The  inability  to  nurse  may  be  due  to  improper  development  of  the 
nursing  center,  or  lack  of  coordination  on  the  part  of  the  pharyngeal 
muscles  and  tongue.  The  latter  is  usually  made  evident  by  a  return 
flow  of  milk  from  the  mouth.  Again,  the  infant  may  be  too  weak  to 
nurse,  or  it  may  not  have  learned  to  suck,  or  vomiting  or  perhaps 
cyanosis  may  prevent  its  feeding  properly.  In  this  group  of  infants 
we  may,  of  necessity,  resort  to  one  of  several  procedures : 

The  use  of  a  fruit  spoon  (Fig.  95)  or,  better  a  large  size  medicine 
dropper  (Fig.  96). 

In  those  infants  who  can  assist  themselves: 

A  small  nursing  bottle  (Fig.  97).  The  1-ounce  bottle  is  provided 
with  small  nipples  the  size  of  those  commonly  sold  on  doll  nursing 
bottles,  which  can  usually  be  obtained  of  proper  quality.  Such  a 
nipple  can  be  made  by  perforating  the  rubber  bulb  of  a  better 
quality  medicine  dropper.  Our  2-ounce  bottle  has  a  larger  neck 
which  takes  the  ordinary  size  nipple.  One  with  a  small  mouth 
piece  must  be  used.  It  should  be  made  of  a  soft  elastic  rubber. 
The  semitransparent  nipples  usually  answer  best. 


INFANTS  TOO  WEAK  TO  NURSE  AT  THE  BREAST        173 


Fig.  95. — Fruit  spoon  which  can  bo  used  for  mouth  or  nasal  feeding.    The  latter  is 

not  recommended. 


Fig.  96. — Large  medicine  dropper  with  a  short  piece  of  soft  rubber  tubing  over 
lower  end  to  prevent  injury  to  the  baby's  mouth.  Most  infants  soon  learn  to  suckle 
on  the  soft  rubber  tube  when  inserted  into  the  mouth.  When  sufficiently  developed 
a  small  bottle  and  nipple  can  be  substituted. 


Fig.  97. — One  ounce  graduated  nursing  bottle  with  small  nipple  approximately 
the  size  of  the  end  of  an  ordinary  medicine  dropper.  Two  ounce  graduated  bottle 
with  a  special  nipple  with  a  small  mouth  piece.  This  nipple  will  fit  on  the  larger  neck 
bottle  sold  on  the  market  and  can  also  be  inverted  for  cleansing.  Another  good 
nipple  is  that  shown  in  type  two  Breck  feeder.    (Fig.  98.) 


174 


METHODS  OF  FEEDING 


The  Breck  feeder  in  the  original,  or  a  modification  which  can  be 
made  by  flanging  the  ends  of  a  urethral  syringe,  using  a  heavy 
rubber  finger-cot  on  one  end  and  a  small  nipple  or  perforated  soft 
medicine-dropper  tip  on  the  other,  will  usually  suffice  (Fig.  98). 
The  second  type  illustrated  has  the  disadvantage  of  having  the  milk 
enter  the  bulb  on  filling  from  the  large  end.  The  bulbs  are  difficult 
to  clean. 


Fig.  98.— Modified  Breck  Feeders.  Type  I:  with  a  small  nipple  at  the  lower 
end  and  an  ordinary  finger  cot  at  the  upper  end.  Type  II:  has  a  large  nipple  at 
the  lower  end  and  a  medicine  dropper  bulb  at  the  upper  end.  The  latter  is  not  a 
safe  model  because  the  milk  must  be  poured  into  the  large  end  and  therefore  enters 
the  bulb  which  is  difficult  to  clean.  Type  III  can  be  made  by  flanging  a  straight 
piece  of  large  tubing  and  using  the  large  nipple  at  one  end  and  the  finger  cot  at  the 
other.  The  glass  part  can  be  blown  by  any  specialty  glass  company  or  the  barrel 
of  an  ordinary  glass  syringe  can  be  drawn  and  flanged  to  take  the  rubber  parts. 

Direct  expression  of  milk  into  the  infant's  mouth  has  proved 
one  of  the  most  valuable  expedients  in  our  hands  as  a  method  of 
teaching  the  infant  the  act  of  nursing. 

Catheter  feeding  is  the  simplest  and  best  method  of  procedure  in 
the  smaller  infants,  if  carefully  practised  by  an  experienced  nurse. 


INFANTS  TOO  WEAK  TO  NURSE  AT  THE  BREAST        175 

Catheter  feeding  should  be  instituted  as  soon  as  fatigue  or  cyanosis 
is  noted  following  other  methods  of  feeding.  A  catheter  (No.  12 
French,  No.  8  American,  No.  5  English)  about  14  inches  in  length 
may  be  attached  to  a  small  funnel,  graduated  glass  tube,  or,  in  case 
of  emergency,  the  glass  barrel  of  a  small  syringe  may  be  used.  All 
food  should  be  carefully  measured  and  administered  slowly  with  a 
minimum  elevation  required  to  obtain  a  free  flow  of  the  milk.     The 


Fig.  99. — Utensils  for  catheter  feeding.  Glass  barrel  of  syringe,  No.  12  French 
catheter  and  one  ounce  graduate  glass.  The  catheter  should  be  marked  at  2  cm. 
intervals  between  the  distances  12  to  20  cm.  above  the  tip.1 

infant  should  be  upon  its  back  on  a  flat  surface  with  the  head  either 
in  the  median  line  or  turned  to  the  right.  The  passage  of  the 
catheter  is  usually  effected  without  difficulty  by  passing  it  in  the 
midline  to  the  pharynx,  gradually  pushing  it  into  the  esophagus. 
The  poorly  developed   reflexes  rarely  cause  retching.     The  dis- 

1  As  there  are  no  short  catheters  marked  in  the  metric  system  on  the  market  it  is 
advisable  to  mark  several  for  ward  use  between  12  and  20  cm. 


176  METHODS  OF  FEEDING 

tance  to  which  the  catheter  is  to  be  passed  is  of  great  importance 
when  we  consider  that  this  procedure  must  be  repeated  at  least  six 
to  eight  times  daily  over  a  considerable  period  of  time.  It  has 
been  our  rule  to  measure  the  distance  from  the  bridge  of  the  nose  to 
the  tip  of  the  ensiform  cartilage,  which  is  usually  in  the  neighbor- 


Fig.  100. — Catheter  feeding.  The  catheter  has  been  passed  for  a  distance  equal 
to  that  from  the  bridge  of  the  nose  to  the  tip  of  the  ensiform  cartilage  measured  with 
the  chin  at  right  angles  to  the  body.  The  lower  end  is  seen  about  1  cm.  above  the 
cardia  in  A,  Fig.  101. 

hood  of  12  to  15  cm.  (Full-term  new-born  infants  average  about 
16  cm.)  The  catheter  is  marked  at  this  point  with  indelible  ink 
and  is  passed  to  this  point  or  about  1  cm.  further  than  this  distance 
which  allows  it  to  reach  the  lower  end  of  the  esophagus  just  above 
the  cardia,  from  which  point  the  food  will  flow  through  the  patent 
cardia.  We  thereby  avoid  irritating  the  gastric  mucosa  and 
stimulation  of  the  reflexes  at  the  cardia.     One  soon  learns  the 


INFANTS  TOO  WEAK  TO  NURSE  AT  THE  BREAST        177 


Fig.  101. — Feeding  baby  with  catheter.  Catheter  feeding  as  carried  out  by  one 
person.  The  head  is  held  at  right  angles  by  the  left  hand,  the  catheter  is  passed 
with  the  right  hand.  Next  the  funnel  is  passed  to  the  left  hand  and  elevated  to  allow 
the  air  to  escape  from  the  stomach.  The  catheter  is  now  compressed  and  slightly 
elevated  and  part  or  all  of  the  feeding  is  poured  in  from  the  graduate  and  allowed  to 
flow  slowly  into  the  stomach.  The  small  sketch  illustrates  the  point  to  which  the 
lower  end  of  the  catheter  should  be  passed. 
12 


178  METHODS  OF  FEEDING 

distance  the  catheter  can  be  passed  in  each  case  in  order  to  avoid 
retching.  The  milk  is  now  allowed  to  flow  into  the  stomach  slowly, 
the  funnel  being  raised  only  slightly  above  the  level  of  the  body, 
usually  6  or  8  inches  will  suffice.  After  the  feeding  the  catheter 
is  firmly  compressed  to  avoid  spilling  milk  into  the  pharynx  during 
its  removal  (Figs.  99,  100  and  101). 

The  infant  should  be  turned  on  its  right  side  following  the  feeding. 
In  the  presence  of  gastric  distention,  raising  the  infant  before  and 
after  feeding  to  the  vertical  position,  avoiding  flexion  of  the  body, 
will  allow  of  the  eructation  of  air  and  frequently  prevent  cyanosis. 
When  the  stomach  is  noticeably  distended  with  gas  before  feeding 
the  catheter  should  be  passed  1  or  2  cm.  further  than  the  mark  on 
the  catheter  before  starting  feeding,  in  order  to  allow  the  gas  to 
escape.  It  is  then  retracted  as  directed  and  feeding  started.  The 
catheter  should  be  passed  with  the  funnel  empty,  so  as  to  allow  of 
this  procedure.  The  catheter  should  then  be  compressed  and  the 
milk  poured  into  the  glass  funnel.  This  allows  the  air  in  the  funnel 
to  escape  thereby  preventing  overdistention  of  the  stomach  by  the 
mixture  of  food  and  air.  The  feeding  period  should  be  as  short  as 
possible  without  undue  haste.  Too  rapid  feeding  is  more  dangerous 
than  too  slow.  Usually  one  to  three  minutes  are  needed.  Two 
nurses  can  be  used  to  advantage  in  catheter  feeding,  but,  as  so 
frequently  happens,  only  one  is  available  during  the  night  feedings. 
Every  nurse  should  be  trained  to  undertake  catheter  feedings  with- 
out assistance.  We  believe  that  turning  the  infant  on  the  right  side 
following  feedings  reduces  the  emptying  time.  Its  position  should 
be  changed  at  least  once  between  feedings  to  avoid  localized  pulmo- 
nary congestion. 

The  Number  of  Feedings.— This  will,  of  necessity,  depend  in  many 
instances  upon  the  question  of  catheter  versus  other  methods  of 
feeding.  Larger  infants  fed  by  catheter  can  often  be  given  sufficient 
food  at  four-hour  intervals  to  meet  their  needs.  In  small  infants 
fed  by  dropper,  bottle  or  other  methods  we  have  experienced  great 
difficulty  in  administering  a  sufficient  quantity  of  food  by  the  long- 
interval  feeding.  As  the  attendants  in  charge  are  frequently  not 
to  be  trusted  with  the  catheter  feeding,  the  short-interval  feeding 
must  be  resorted  to. 

For  this  purpose  we  have  grouped  our  infants  into  two  classes— 
those  weighing  under  1500  gm.  and  those  weighing  above  this  figure. 
These  figures  are  arbitrary  and  will  not  require  rigid  adherence. 
The  classification  is  based  on  the  tendency  of  the  smaller  infants 
to  become  exhausted  when  the  feedings  are  too  long  continued. 
The  smaller  hand-fed  infants  are  fed  at  two-hour  intervals  during 
the  day  and  three  hours  at  night.  The  larger  on  the  three-hour 
basis.  When  catheter  feeding  is  the  method  of  choice,  even  in 
the  smaller  infants  six  to  eight  is  usually  the  maximum  number 


INFANTS  TOO  WEAK  TO  NURSE  AT  THE  BREAST         170 

needed  in  twenty-four  hours.  It  must  be  remembered  that  all 
feedings  are  dependent  on  the  general  development  of  the  infanl 
in  relation  to  its  digestion  and  metabolism  and  its  ability  to  retain 
the  food  administered,  as  well  as  on  the  attendant  complications  to 
feeding,  such  as  asphyxia,  cyanosis  and  gastric  distention. 

When  to  Start  Regular  Feeding.— This  is  a  question  of  great 
importance  to  these  infants,  because  of  the  tendency  to  develop 
acute  inanition.  Therefore  a  regular  feeding  regimen  must  be 
started  early.  Human  milk  is  essential  to  a  low  mortality.  As 
little  can  be  expected  from  the  mother  for  several  days,  it  becomes 
necessary  to  obtain  the  limited  supply  necessary  from  another 
mother,  preferably  a  wet-nurse.  If  for  any  reason  it  is  unlikely 
that  the  mother  may  be  depended  upon,  either  because  of  illness  or 
local  breast  conditions,  immediate  search  should  be  begun  for  a 
supply  of  breast  milk. 

Feeding  During  the  First  Day.— During  the  first  day  it  is  our  custom 
to  withhold  milk  for  twelve  hours  until  the  respiratory  and  circula- 
tory functions  are  well  established.  During  the  second  twelve  hours 
one  to  three  feedings  of  breast  milk  may  be  started  if  the  infant's 
condition  warrants. 

Feeding  from  the  Second  to  the  Tenth  Day.— The  second  to  the 
tenth  days  may  be  grouped  together  as  the  second  feeding  period 
for  practical  purposes. 

From  the  second  day  they  should  be  fed  regularly,  day  and  night, 
the  number  and  time  of  feedings  depending  to  a  great  extent  on 
whether  the  food  be  given  with  or  without  the  use  of  a  catheter; 
second,  upon  the  gastric  capacity;  third,  upon  the  infant's  general 
condition. 

Further  fluids,  preferably  inert,  such  as  water  or  1  per  cent 
lactose  solution,  are  administered  to  compensate  for  the  loss  of 
body  fluids  through  the  kidneys,  bowels,  lungs  and  skin.  The 
infant  requires  about  one-sixth  of  its  body  weight  of  water,  inclu- 
sive of  that  contained  in  the  milk,  in  twenty-four  hours  while  in 
the  heated  bed.  Such  quantities,  however,  should  not  be  attempted 
on  the  first  days;  usually  it  will  be  possible  to  approximate  one- 
eighth  of  the  body  weight  by  the  fourth  day.  The  early  feedings 
must  necessarily  be  small  and  the  increases  gradual. 

Each  Infant  Fed  Individually . —They  must  be  considered  individu- 
ally, as  it  is  impossible  to  formulate  definite  rules  for  feeding,  at 
least  during  the  first  ten  days. 

1.  We  must  have  a  definite  idea  of  the  minimum  food  require- 
ments for  life. 

2.  The  amount  of  food  necessary  to  maintain  at  least  a  stationary 
weight. 

3.  The  amount  of  food  needed  to  meet  the  requirements  for 
growth  and  development. 


180  METHODS  OF  FEEDING 

Approximately  one-seventh  of  the  body  weight  of  fluids  and 
human  milk  of  a  food  value  of  70  calories  per  kilo  every  twenty- 
four  hours  are  required  to  maintain  life.  Little  can  be  expected 
in  the  way  of  weight  increase  until  90  calories  are  reached,  and 
depending  on  their  weight,  body  surface  and  physiological  develop- 
ment, their  later  needs  will  approximate  100  to  140  calories  per 
kilo  body  weight  (Table  IV).  In  exceptional  cases  it  may  be 
necessary  to  feed  breast  milk  in  amounts  equaling  160  to  200  calories 
per  kilo.  Such  infants  are  usually  markedly  underweight  for  their 
fetal  age. 

Infants,  to  fulfil  all  their  needs,  will  therefore  require  from  140 
to  200  cc  of  breast  milk  per  kilo,  or  about  one-seventh  to  one-fifth 
of  their  body  weight  daily.  They  can,  however,  maintain  life 
on  100  cc  and  hold  their  weight  in  most  cases  on  130  cc  per  kilo. 
Exceptionally,  we  have  fed  as  high  as  300  cc  per  kilo  in  under- 
weight infants.  The  latter  must  be  carefully  observed  for  signs  of 
overfeeding,  such  as  vomiting,  gastric  dilatation  and  cyanosis. 

Beginning  (in  most  cases  by  the  second  day)  with  20  to  40  cc 
human  milk  per  kilo  of  body  weight,  the  quantity  may  be 
increased  by  8  to  15  cc  daily  per  kilo  until,  usually  by  the  tenth 
dav,  feedings  averaging  from  80  to  140  cc  per  kilo  can  be  fed 
(Tables  I,  II  and  III). 

AVERAGE  HUMAN  MILK  DIETS  REQUIRED  BY  PREMATURES 
DURING  THEIR  FIRST  TWENTY-ONE  DAYS. 

After  the  tenth  day  in  larger  infants  the  milk  can  be  increased 
more  rapidly,  usually  by  15  and  occasionally  20  cc  per  day,  until 
from  140  to  200  cc  (100  to  140  calories)  per  kilo  are  fed,  the  methods 
of  giving  food,  as  well  as  its  frequency  being  dependent  on  the 
general  development  of  the  infant. 

The  size  of  individual  feedings  will  vary  with  the  method  of  feed- 
ing. When  catheter  fed,  six  to  eight  feedings  a  day  are  given,  with 
an  average  of  from  4  to  6  cc  per  feeding  during  the  second  day. 
The  feedings  are  now  increased  daily  by  an  average  of  2  cc  per 
feeding.  When  feeding  from  the  bottle  or  by  dropper,  smaller 
feedings  are  usually  given  more  frequently— usually  from  eight  to 
ten  daily,  although  twelve  may  be  needed  when  larger  feedings  are 
not  retained.  Begin  with  2  to  4  cc  and  increase  by  1  or  2  cc  per 
feeding  on  each  succeeding  da}',  until  140  to  200  cc  per  1  kilo  per 
day  is  reached. 

The  food  and  water  to  be  administered  should  be  noted  in  writing 
for  the  nurse's  instruction  each  day,  after  a  thorough  inspection 
of  the  infant  and  its  clinical  chart. 

The  diet  of  a  premature  infant  making  a  satisfactory  gain  in  freight 
should  not  be  changed  arbitrarily  without  a  well-defined  indication. 


TABLE   I. 

—  INFANTS   APPROXIMATING    1000 

3M    (2   POUNDS) 

IN  WEIGHT. 

Milk  for 

twenty-four 

hours, 

cc. 

Bottle  fed. 

Catheter  fed. 

Addi- 
tional 

water. 

Total 

fluids. 

Calories, 
per  kilo. 

Fluid 
intake 

Day. 

Number.        Amount . 

Number. 

Amount. 

vs. 
body 

weight. 

1 

4-12 

3  to  2           2-4 

3-2 

4 

45 

50-60 

3-8 

1/20 

2 

20-40 

10  to  8       2.0-  5.0 

6 

5 

60 

80-100 

14-28 

1/12 

3 

30-50 

" 

3.0-  6.0 

u 

5-8 

70 

100-120 

21-35 

1/9 

4 

35-60 

" 

3.5-  7.5 

" 

6-10 

80 

115-140 

21   42 

1/8 

5 

45-70 

" 

4.5-  9.0 

" 

7-12 

" 

125-150 

31-49 

1/7 

6 

50-80 

" 

5.0-10.0 

" 

8-13 

" 

130-160 

35-56 

" 

7 

00-90 

n 

6.0-11.0 

" 

10-15 

<t 

140-170 

42-63 

" 

8 

65-100 

6.5-13.0 

" 

11-16 

" 

145-180 

45-70 

1/6 

9 

75-110 

7.5-14.0 

" 

12-18 

" 

155-190 

52-77 

" 

10 

80-120 

8.0-15.0 

" 

13  20 

70 

150-190 

50  si 

" 

11 

90-130 

9.0-16.0 

" 

15-22 

" 

160-200 

63-91 

12 

95   140 

9.5-17.0 

" 

16-23 

" 

165-210 

66-98 

" 

13 

105-150 

10.5-18.0 

" 

18-25 

" 

175-220 

73-105 

1/5 

14 

110-160 

11.0-20.0 

" 

19-2G 

60 

170-220 

77-112 

" 

15 

120- 170 

8               13-21 

" 

20-28 

" 

180-230 

84-119 

" 

16 

125-180 

15-23 

" 

21-30 

" 

185-240 

87-126 

" 

17 

135-190 

17-24 

" 

22-31 

50 

185-240 

94-133 

it 

18 

140-200 

18-26 

" 

24-33 

" 

190-250 

98-140 

19 

150-210 

19-27 

" 

25-35 

40 

190-250 

105-147 

20 

160-220 

20-28 

" 

26-36 

" 

200-260 

112-154 

" 

21 

165-230 

21-29 

27-38 

30 

195-260 

115-161 

The  caloric  requirements  are  figured  on  the  basis  of  a  retained  birth  weight.  Water  additions 
recommended  are  calculated  on  the  average  between  high  and  low  milk  requirements.  The  necessity 
for  further  water  after  the  twenty-first  day  must  of  necessity  vary  with  the  individual  case.  Water 
may  often  be  discontinued  when  one-fifth  of  the  body  weight  in  breast  milk  is  being  fed  in  twenty- 
four  hours. 


TABLE    II. 

—  INFANTS   APPROXIMATING    1500 

3M.    (3 

pounds) 

IN  WEIGHT. 

Milk  for 

twenty-four 

hours. 

ce. 

Bottle  fed. 

Catheter  fed. 

Addi- 
tional 
water. 

Total 
fluids. 

Calories, 

per  kilo. 

Fluid 
intake 

Day. 

Number.        Amount. 

Number. 

Amount. 

vs. 

body 

weight. 

1 

6-15 

3  to  2 

3-5 

3-2 

5 

60 

65-75 

3-7 

1/20 

2 

30-60 

10  to  8 

3-7 

6 

5-10 

90 

120-150 

14-28 

1/12 

3 

40-75 

tt 

4-9 

" 

6-12 

100 

140-175 

18-34 

1/10 

4 

50  90 

" 

5-11 

" 

8-15 

" 

150-190 

24-42 

1/9 

5 

60-105 

" 

6-13 

" 

10-17 

120 

180-225 

28-49 

1/8 

6 

70-120 

" 

7-15 

" 

12-20 

" 

190-240 

32-56 

1/7 

7 

80-135 

" 

8-17 

" 

13-22 

" 

200-255 

36-63 

it 

8 

90-150 

" 

9-19 

" 

15-25 

" 

210-270 

42-70 

" 

9 

100-165 

" 

10-21 

" 

17-22 

" 

220-285 

46-77 

1/6 

10 

110-180 

" 

11-23 

" 

18-30 

" 

230-300 

52-84 

" 

11 

120-195 

" 

12-24 

" 

20-32 

" 

240-315 

56-91 

" 

12 

130-210 

" 

13-26 

" 

22-35 

" 

250-330 

60-98 

" 

13 

145-225 

" 

14^28 

" 

23-37 

" 

260-345 

66-105 

1/5 

14 

150-240 

" 

16-30 

" 

25-40 

" 

270-360 

70-112 

" 

15 

160-255 

8 

18-32 

" 

27-42 

100 

260-355 

74-119 

" 

16 

170-270 

20-34 

" 

2S    I.". 

80 

250-350 

80-126 

" 

17 

180-285 

22-36 

" 

30-47 

" 

260-365 

M    133 

« 

18 

190-300 

24-38 

" 

32-50 

60 

250-360 

88-140 

u 

19 

200-315 

" 

26-40 

" 

33-52 

" 

260-375 

94-147 

" 

20 

210-330 

" 

28-42 

" 

35-55 

40 

250-370 

98-154 

" 

21 

220-345 

30-44 

37-57 

260-385 

102-161 

Water  administration  recommended  is  for  infants  taking  the  average  between  low  anil  high  milk 
requirements.  If  diet  is  well  taken  and  one-fifth  the  body  weight  in  milk  is  being  fed,  the  water  may 
now  be  discontinued. 


182  METHODS  OF  FEEDING 

TABLE   III.— INFANTS  APPROXIMATING  2000   GM    (4  POUNDS)    IN  WEIGHT. 


Milk  for 

twenty-four 

hours, 

CO. 

Bottle  fed. 

Catheter  fed. 

Addi- 
tional 
water. 

Total 

fluids. 

Calories, 
per  kilo. 

Fluid 
intake 

Day. 

Number. 

Amount. 

Number. 

Amount. 

i  8. 

body 
weight. 

1 

20-30 

4 

5-8 

3 

7-10 

80 

100-110 

7-10 

1/20 

2 

40-80 

8 

5-10 

6 

7-13 

100 

140-180 

14-28 

1/12 

3 

55-100 

" 

7-12 

" 

9-16 

120 

175-220 

20-35 

1/10 

4 

70-120 

" 

8-15 

" 

11-20 

" 

190-240 

24-42 

1/9 

5 

85-140 

" 

10-18 

14-23 

160 

245-300 

30-49 

1/8 

6 

100-160 

" 

12-20 

" 

16-27 

260-320 

35-56 

1/7 

7 

115-180 

" 

14-22 

a 

19-30 

275-340 

40-63 

" 

8 

130-200 

u 

16-25 

" 

21-33 

290-360 

45-70 

" 

9 

145-220 

" 

18-27 

" 

24-37 

305-380 

50-77 

1/6 

10 

160-240 

" 

20-30 

" 

26-40 

320-400 

56-84 

" 

11 

175-260 

" 

22-32 

" 

29-43 

335-420 

61-91 

" 

12 

190-280  j 

24-35     . 

32^7 

350-440 

66-98 

" 

13 

205-300 

26-37 

34-50 

365-460 

72-105 

1/5 

14 

220-320 

28-40 

37-53 

140 

365-460 

77-112 

15 

235-340  !        "              30-42 

39-57 

120 

355-460 

82-119 

<< 

16 

250-360  1        "              32-45 

42-60 

100 

350-460 

87-126 

" 

17 

265-380                          34-47 

44-63 

80 

345-460 

92-133 

" 

18 

280-400 

36-50 

47-67 

60 

340-460 

98-140 

" 

19 

295-420 

38-52 

49-70 

40 

335-460 

103-147 

" 

20 

310-440 

40-55 

52-73 

20 

330-460 

108-154 

" 

21 

325-460 

41-57 

54-77 

0 

345-460 

113-161 

The  necessity  for  further  water  diet  after  the  twenty-first  day,  or  increases  over  amounts  recom- 
mended in  the  schedule  must  of  necessity  vary  with  the  individual  case. 

TABLE   IV.  — CALORIC   REQUIREMENTS   PER   KILOGRAM    BODY 

WEIGHT. 

Values  Recommended  by  Different  Authors. 

Salge1 130  to  150 

Samelson2 115  to  150 

Oppenheimer3 120  to  130 

Czerny-Keller4 100  to  120 

Langstein-Meyer5 120  to  130 

Budin6  (average) 140 

Birk7 100  to  160 

Reiche8  (in  those  under  2000  grams) 120  to  130 

(in  those  over  2000  grams) 95  to  110 

Oberwarth" 120  to  160 

Morse  and  Talbot10  (average) 120 

E.  Moll11 110  to  120 

Cook,  P.12 120  to  200 

1  Einfiihring  in  die  moderne  Kinderheilkunde,  Berlin,  1909. 

2  Ztschr.  f.  Kinderh.,  1911,  11,  18. 

3  Med.  Klin.,  1908,  6,  92. 

4  Des  Kindes  Ernahrung  usw.  Leipsig  u.  Wien,  1912. 

6  Siluglingsnahrung  u.  Sauglingsstoffwechsel,  Wiesbaden,  1914. 

6  The  Nursling,  London,  1907. 

7  Sauglingskrankheiten,  1913. 

s  Ztschr.  f.  Kinderh.,  1914,  12,  369. 

9  Ergeb.  d.  Inn.  Med.  u.  Kinderh.,  1911,  7,  191. 

10  Diseases  of  Nutrition  and  Infant  Feeding,  Macmillan  &  Co.,  New  York,  1920. 

11  Ztschr.  f.  Kinderh.,  1919,  21,  329. 

12  Arch.  Pediat...  1921,  37,  201. 


AVERAGE  HUMAN  MILK  DIETS  183 

These  feedings  should,  as  rapidly  as  possible,  be  supplemented 
by  water  or  sugar  water  by  mouth,  or  saline  by  rectum  to  meet 
the  required  140  to  200  cc  per  1  kilo  of  fluids  required  daily. 

Initial  Weight  Loss.— The  lower  the  birth  weight,  the  greater  is 
the  percentage  weight  loss  to  be  expected.  Artificially-fed  infants 
lose  more  weight  than  breast-fed  infants  in  whom  the  diet  is  started 
early.  An  average  loss  of  not  more  than  8  to  12  per  cent  of  the 
birth  weight  may  be  considered  as  satisfactory.  By  regular  admin- 
istration of  inert  fluids  during  the  first  days  the  total  loss  can  fre- 
quently be  reduced  to  5  per  cent. 

Daily  Gains.— These  are  not  necessarily  in  proportion  to  the 
changing  quantity  of  milk  administered,  as  many  factors,  such  as 
condition  of  the  bowels,  quantity  of  urine  passed,  temperature  of 
the  infant's  surroundings  and  numerous  other  factors  will  necessarily 
influence  the  weight. 

An  average  daily  gain  greater  than  20  gm.  is  unusual  when  the 
infant's  food  is  limited  to  one-sixth  of  its  body  weight. 

Although  occasionally  an  infant  holds  its  birth  weight,  most 
infants  do  not  regain  their  birth  weight  before  the  end  of  the  second 
or  third  week. 

In  the  very  small  prematures  an  average  daily  gain  of  10  to  15 
gm.  with  a  doubling  in  birth  weight  in  from  seventy-five  to  one 
hundred  days  may  be  considered  satisfactory.  In  the  larger 
infants  a  gain  of  15  to  20  gm.  may  be  expected  with  a  doubling  in 
birth  weight  in  from  fifty  to  one  hundred  days.  The  birth  weight 
is  frequently  trebled  within  one  hundred  and  eighty  days. 

Special  Feeding  Rules.— 1.  Food  requirements  which  have  been 
recommended  must,  of  necessity,  be  considered  as  relative,  varia- 
tions being  to  a  great  extent  influenced  by  the  physiological  and 
anatomical  developments  and  to  a  not  inconsiderable  extent  by 
the  temperature  and  humidity  of  the  air  surrounding  the  infant 
and  the  type  of  clothes  in  which  it  is  dressed. 

2.  Each  day  the  total  amount  of  food  as  indicated  for  the  indi- 
vidual infant  is  to  be  estimated,  in  order  that  the  required  food 
and  water  will  be  administered.  The  number  and  amount  of 
feedings  will,  of  necessity  vary,  but  each  must  also  be  estimated 
for  each  day. 

3.  When  a  number  of  infants  are  to  be  fed  by  one  wet-nurse, 
careful  calculation  of  the  day's  needs  of  each  infant  must  be  made 
by  the  floor  nurse  for  the  information  of  the  nurse  in  charge  of  the 
milk  supply. 

4.  Expression  of  breast  milk  should  be  performed  at  regular 
intervals,  preferably  six  times  a  day  at  four-hour  periods  day  and 
night.  The  sixth  expression  during  the  night  may,  however,  be 
omitted  if  the  supply  is  in  excess.     It  is  only  by  regular  and  com- 


184  METHODS  OF  FEEDING 

plete  emptying  of  the  breasts  by  expression  that  a  milk  supply 
can  be  maintained  for  an  indefinite  period,  unless  there  is  a  second 
baby  which  can  be  placed  at  the  breast. 

5.  Human,  as  well  as  cows'  milk,  must  be  obtained  under  aseptic 
conditions  and  kept  clean  and  cool  until  ready  for  the  infant. 
To  preserve  milk  properly,  the  ice  box  must  register  less  than  50°  F. 
The  food  should  be  slowly  warmed  before  feeding. 

6.  The  boiled  water  to  be  fed  must  be  carefully  calculated, 
and  it  must  represent  the  difference  between  the  total  fluids  indi- 
cated which  will  usually  average  from  one-eighth  to  one-fifth  of 
the  body  weight  of  the  infant  for  twenty-four  hours  and  the  amount 
of  fluid  given  as  milk.  The  water  for  each  day  should  be  measured 
and  set  aside  in  an  individual  stoppered  bottle  each  morning. 

It  should  be  administered  between  the  milk  meals  or  occasionally 
there  may  be  an  indication  for  diluting  the  milk  with  part  of  it. 
In  order  to  administer  the  full  day's  water  supply  in  some  of  the 
small  infants  and  those  who  vomit,  it  may  be  necessary  to  give 
water  in  small  quantities  one,  two  and  even  three  times  between 
milk  feedings.  If  unable  to  swallow  properly  water  must  be  given 
by  catheter.  In  larger  infants  only  a  few  water  feedings  a  day 
may  be  needed,  and  usually  by  the  third  or  fourth  week,  one-seventh 
or  one-fifth  of  the  body  weight  in  milk  can  be  fed  daily.  At  this 
time  the  water  may  be  discontinued  unless  it  is  necessary  to  supply 
external  heat  of  considerable  degree,  or  the  infant  has  a  fever, 
both  of  which  necessitate  increased  amount  of  fluids. 

The  maximum  feeding  figures  as  given  in  the  tables  for  1000-, 
1500-  and  2000-gm.  infants  from  the  seventeenth  to  the  twenty- 
first  days  and  which  range  from  140  to  161  calories  may  seem  exces- 
sive, but  it  should  be  remembered  that  in  figuring  these  feedings 
they  are  based  on  birth  weight  without  allowance  for  weight  increase 
which  is  usually  seen  during  the  third  week  of  life  of  these  infants. 
Allowance  for  these  weight  increases  are  covered  by  the  maximum 
total  diet  recommended.  Not  infrequently  the  infant  requires 
more  rapid  increases  in  its  diet  than  those  quoted  as  the  maximum 
feedings.  The  physician  must  be  the  best  judge  of  the  needs  of 
the  individual  case. 

Feedings  After  the  Twenty-first  Day.  — Usually  by  the  twenty-first 
day,  the  food  requirements  of  the  infant  are  quite  well  established 
and  a  careful  observation  of  the  infant's  weight,  stools,  disposition 
and  equally  important,  its  body  temperature  will  decide  the  future 
food  requirements. 

The  water  requirement  will,  to  a  great  extent,  be  dependent 
upon  the  supply  of  artificial  heat  and  the  presence  of  fever.  Ordi- 
narily by  the  beginning  of  the  fourth  week,  one-seventh  to  one- 
fifth  (140  to  200  cc  or  100  to  140  calories  per  kilo)  of  the  infant's 
body  weight  in  the  form  of  breast  milk  is  needed  to  maintain  proper 


MENACE  II T MAX   MILK   DIETS 


185 


growth.  Occasionally  it  is  necessary  to  exceed  these  amounts  in 
the  poorly  nourished  premature.  If  the  physiological  functions  are 
seemingly  normal  the  scale  is  the  deciding  factor  in  indicating 
food  increases  or  decreases. 

As  the  infant  takes  on  weight  and  becomes  fat  with  a  rounding 
of  the  features  and  the  body  as  is  the  case  in  successfully  breast- 
milk-fed  prematures,  the  total  milk  administration  can  be  held  at 
one-sixth  and  not  infrecpiently  one-seventh  of  the  body  weight, 
and  normal  weight  increases  may  still  be  maintained. 

Mixed  Feeding.  When  human  milk,  even  though  in  small  quan- 
tities, is  available,  it  should  form  the  basis  of  the  diet,  and  cows' 
milk  mixtures  should  be  supplemental  (Cases  1  to  14).  Experience 
has  taught  us  to  expect  a  rapidly  increasing  mortality  when  less 
than  50  per  cent  of  the  food  is  other  than  human  milk. 


Fig.  102. — Baby  Juanita.     Age,  one  day;   weight,  1070  gm. 


2200 
2000 

1800 

WEIGHT     1G00 
GM.          14Q0 

1200 

1000 

500 

FOOD       400 

CC.        300 

200 

100 

June                                      July                                                  August                                      September 
4    7  10  M 1019332328  1    4    7  101310 193S23S8S1  I  C   0  13 15 18812427  SO  3   3   8  111417 

LJ_ 

L 

j- 

1 

il 

-r 

ir 

V. 

L 

lJ 

J| 

i 

C  M  nR|[   q    PE  1,'    Kit  O. 

15 'J      152      K.2      1''.2      107      170      171      103 

i,> 

10a      140      1:/.' 

Fig.  103. — Baby  Juanita.  Weight  and  food  curves  and  calories  per  kilogram 
weight.  The  patient  entered  June  4,  aged  one  day;  weight,  1070  Km.;  condition 
fair.  Discharged  September  18;  aged  one  hundred  and  five  days:  weight,  21S0  gm. 
An  ideal  curve  with  an  energy  quotient  ranging  between  132  and  170,  and  an  average 
daily  gain  of  12.5  gm.  over  a  period  of  ninety  days. 


186 


METHODS  OF  FEEDING 


Fig.  104. — Baby  Silvis  B.     Age  when  taken,  seven  months;     weight,  13  pounds. 


July                                                  August                                                           September 

8    11    14    17  20  23  27  30    3     5     8    11    14  17  20  23  2G  29    1      4      7     10  14 

2200 
2009 
1800 

WEIGHT 

GM.        loOO 

1100 
1200 
1C00 

500 
400 
FOOD    c.c.   300 
200 
100 

15 

^0 

H 

ON 

E 

CALORIES  PER  KILO. 

11 

54 

95 

no 

ni 

110 

i:;i 

142 

|148| 

162 

Fig.  105. — Baby  Silvis  (Italian).  Weight  and  food  curve  and  calories  per  kilo- 
gram. Born  July  5,  admitted  July  8;  weight,  1050  gm.;  lowest  weight,  980  gm., 
on  his  tenth  day  of  life.  Initial  loss,  70  gm.  Discharged  September  11;  aged 
sixty-five  days;  weight,  1580  gm.  Regained  entrance  weight  fourteenth  day  in 
hospital  when  seventeen  days  old. 


Average  human  milk  diets 


18? 


1  week  aver 

2 

3 

4 

5 

G 

7 

8 

9 


Average  Daily  Gains  in  Grams. 

age  loss  per  day   ==    8.57  gm.;   average    48.9  cal.  per  kilo, 
gain 


10.0       " 

91.0 

4.28     " 

109.0 

8.5       " 

121.8 

10.0       " 

119.0 

10.0         " 

137.6 

14.0       " 

136.0 

11.8       " 

142.6 

11.8       " 

1  12.6 

Fig.  106.— Baby  Allen  B.     Age,  eight  days;   weight,  1135  gm. 


J 
1700 

1500 

WEIGHT 
GM. 

1300 
1100 

500 

400 

FOOD   c.c.  300 

200 
100 

cine                                          July                                                               August 

2  15  18  21    24  83   30    3     G     9    12  15  18   21  24   97  80    3     5     8     11    14  17 

CALORIES  PER  KILO. 

SO 

.,.; 

75 

9G 

kki 

107 

mi 

I 'JO 

122 

Fig.  107. — Baby  Allan  B.  Weight  and  food  curves  and  calories  per  kilogram. 
Born  June  5,  admitted  June  12;  weight  1135  gm.  Discharged  August  1G,  weight, 
1655  gm.;  age,  sixty-four  days.  Regained  entrance  weight  fifteenth  day  in  hospital 
Initial  loss    =  35  gm. 


188 


METHODS  OF  FEEDING 


Average  Daily  Gain  in  Grams. 

1  week  average  loss  per  day  =    5.0    gm.;  average    30.2    cal.  per  kilo. 

2  "            "        gain         "         =     2.14     "  "          62.87 

3  "           "           "           "         =    6.4       "  "          75.3 

4  "           "           "           "         =  14.28     "  "          94.7 

5  "           "           "           "         =    5.7       "  "  96.4 

6  "           "           "           "         =     7.1       "  "        105.6 

7  "           "           "           "         =  15.7       "  "        107.1 

8  "            "           "           "         =  14.1        "  "          95.6 

9  "            "           "           "         =  12.1       "  "        112.6 


Fig.  108. — Baby  Peggy.     Age,  three  days;    weight,  1185  gm. 


Fig.  109. — Baby  Peggy.     Age,  forty-three  days;    weight,  2155  gm. 


AVERAGE  HUMAN  MILK  DIETS 


189 


2300 

2100 
1900 

WEIGHT 

GM.         lt0Q 

1500 

1300 

1100 

GOO 
500 

FOOD         400 

cc-       300 
200 
100 

August                                         September 
10    13    1C   1!>  22  25  2*  31    3     O     !)    12   15  18  21 

r_ 

-ALORIES  PER  KILO.1  50 

Hi 

i:.: 

!.-.< 

131 

1  •.'." 

171 

16: 

Fig.  110. — Baby  Peggy.  Weight  and  food  curve  and  calories  per  kilogram. 
Admitted  August  7;  weight,  1185  gm.  Discharged  September  19;  weight,  2155 
gm.;     age,  forty-three  days.     No  initial  loss. 

Average  Daily  Gain  in  Grams. 
1  week  average  gain  per  day  =     7.14  gm.;    average  105.7    cal.  per  kilo. 


2      ' 

'           "           "           ' 

=  22.8       " 

142.5 

3      ' 

'           "           "           ' 

=  15.7       " 

155.9 

4      ' 

'           "           "           ' 

=  20.0       " 

114.15 

5      ' 

'           "           "           ' 

=  30.7       " 

145.3 

6      ' 

'           "           "           ' 

=  33.1       " 

146.0 

7      ' 

'      (3  days)     " 

=  28.33     " 

149.0 

Fig.  111.— Baby  Grace  A.     Age,  three  days;   weight,  11S0  gm. 


190 


METHODS  OF  FEEDING 


Fig.  112.— Baby  Grace  A.     Age,  eighty-nine  days;    weight,  1875  gm. 


June                 July                                                     iugust                                                       September 
20  23  2G  29  2    5     8   1114  17  20  23  2G  29   1    4     7    10  13  IG  19  22  25  28  31   3    G    9   12  15 

1800 
1G00 

WEIGHT    U()0 
GM. 

1200 

1000 

600 
500 
FOOD  c.c.   400 
300 
200 
100 

— 

1 

— ' 

CALORIES  PER  KILO. 

50 

78 

U 

72 

Til 

105 

120| 

i2s; 

138 

11.: 

fiu 

w 

Fig.  113.— Baby  Grace  A.  Weight  and  food  curve  and  calories  per  kilogram. 
Born  June  17,  admitted  June  20;  weight,  1180  gm.  Discharged  September  14; 
weight,  1875  gm.;  age,  seventy-seven  days.  Regained  entrance  weight  thirty- 
sixth  day  in  hospital.     Initial  loss,  110  gm. 


Average  Daily  Gain  in  Grams. 

1  week  average  loss  per  day  =  13.57  gm.;   average    36.36  cal.  per  kilo, 
gain 

3  " 

4  " 

5  " 

6  " 

7  " 

8  " 

9  " 

10  " 

11  "      (4  day.) 


2.14     " 

74.5      " 

1.4       " 

72.5      " 

1.4       " 

70.2       " 

5.7       " 

82.2       " 

15.0       " 

105.6       " 

15.0       " 

120.4       " 

12.14     " 

128.9       " 

16.4       " 

131.1       " 

15.0      " 

129.2       " 

20.0       " 

113.3       " 

Fig.  114.— Peter  P. 


Taken  when  sent  home.     Weight  at  birth,  1220  gm.;    weight 
when  sent  home,  2810  gm. 


May     June                                       July                                             August                                   Sept. 

20  20  1    i    J10131010222528  1   1    7  10131010222528313  6    0121518212427  80  2  5    8  11 

2500 
2300 
2100 
1900 

WEIGHT      1700 

1500 
1300 
1100 
1900 

600 
500 

FOOD          400 

c.c.         300 
200 
100 

- 

"" 

r 

1_ 

,_ 

- 

CALORIES  PER  KILO. 

10 

80 |      110     |      1)0 

■•: 

115 

105 

1     120 

122 

135 

155 

111 

Fig.  115.— Baby  Peter  P.  Weight  and  food  curves  and  calories  per  kilogram. 
Born  May  26,  admitted  May  26;  weight  1175  gm.  Discharged  September  11; 
weight  2480  gm.;  age,  one  hundred  and  eight  days.  Regained  entrance  weight 
on  thirty-second  day  in  hospital,  when  thirty-two  days  old.  Initial  loss  =  220  gin. 
Double  birth  weight  in  one  hundred  days, 


192 


METHODS  OF  FEEDING 


Average  Daily  Gain  in  Grams. 


1  week  average  loss  per  day  =  15.0    gm.;    average    22.6    cal.  per  kilo. 


2   ' 

'     "    "     ' 

=  12.14  " 

82.23  ' 

3   ' 

"   gain 

=  13.57  " 

107.0 

4   ' 

t            it           a           i 

=  12.14  " 

111.0   ' 

5   ' 

i            "     "     "    =  10.0   " 

102.0   ' 

6   ' 

'     "     "     ' 

=  8.7   " 

115.0   ' 

7   ' 

t                it               n               t 

=  10.0   " 

113.8   ' 

8   ' 

(nut 

=  8.5   " 

108.0   ' 

9   ' 

'                 "                "                ' 

=  15.7   " 

117.0   ' 

10   ' 

'                 "                "       ' 

=  15.0   " 

126.0   ' 

11   ' 

'       "       "       ' 

=  14.2   " 

132.0   ' 

12   ' 

t                 it                it               t 

'    =  22.8   "      ' 

143.0   ' 

13   ' 

'  (in  12  days)    ' 

=  22.0   " 

150.0   ' 

14   ' 

'  (in  12  days)    ' 

=  28.75  " 

145.4   ' 

Fig.  116.— EthnaH, 


AVERAGE  HUMAN  MILK  DIETS 


193 


1 

July                                    August                                           September                                   Octolier 
12  IS  1*2124  27  SO  8    5    8   11 14  17  SO  23  SO  89   14     7  10  IS  1G10S8  85  88   1     4     7 

2G00 
2400 
2200 

WEIGHT   2000 
GM. 

1800 
1G00 
1400 

500 
400 

FOOD  C.C.    300 

200 
100 

r^. 

Lp 

1 

rL 

1 

r 

r^ 

n 

/ 

1 

P 

s 

IT 

J 

CALORIES  PER  KILO. 

120, 

L37 

■u 

•JIG 

817 

i 

3 

;-ji 

'.ID 

Fig.  117. — Baby  Ethna  H.  Showing  weight  and  food  curves  and  calories  per 
kilogram  weight.  The  patient  entered  the  hospital  July  9,  aged  one  day;  weight, 
1360  gm.;  condition  fair.  Discharged  October  5;  aged  eighty-eight  days;  weight, 
2512  gm.  Showed  a  steady  increase  after  137  calories  was  reached  and  continued 
to  grow  steadily  until  220  was  fed.  The  growth  averaged  only  13  gm.  daily,  being 
lower  than  several  infants  fed  with  a  much  lower  energy  quotient. 


Fig.  118. 


13 


-Joseph  and  Edward  R.  (twins).     Age,  three  days. 
Edward,  1360  gm.;   Joseph,  1190  gm. 


Birth  weight: 


194 


METHODS  OF  FEEDING 


May              June                                   July                 May           June                                     July 
203326391  4    7  1013161922252S1    4   7  1013    202326291  4    7  10 13161922252* 1  4   7  10  13 

2100 
1900 

1700 

WEIGHT      1500 
GM. 

1300 

1100 

GOO 

FOOD           500 

F  °          400 

cc.         300 

2C0 

100 

- 

— 

l_ 

r^ 

1 — 

i— 

_ 

CALORIE1;  PER  KILO. 

(0 

86J      IK 

.05 

Ji 

H- 

t:> 

-•■ 

10 

12! 

... 

V?l 

Fig.  119. — Baby  Joseph  R.  and  Baby  Edward  R.  (twins).  Born  May  17,  admitted 
May  20.     Discharged  July  13;   age,  sixty  days.     Mother  died  third  day  after  labor. 

Joseph  R. — Age,  three  days;  entrance  weight,  1190  gm.;  discharge  weight,  1950 
gm.  Regained  entrance  weight  on  twelfth  day  in  hospital,  when  fifteen  days  old. 
Initial  loss  =  40  gm. 


Average  Daily  Gain  in  Grams. 


1  week  average  loss  per  day 


gain 


(6  days) 


=    3.57  gm.;   average    33.5  cal.  per  kilo. 

=    8.57  "  "  86.8  " 

=  19.29  "  "  110.7  " 

=  10.0  "  "  107.0  " 

=  17.8  "  "  106.2  " 

=  15.0  "  "  98.9  " 

=  20.7  "  "  140.7  " 

=  20.0  "  "  144.4  "           " 


Edward  R. — Age,  three  days;  entrance  weight,  1360  gm.;  discharge  weight,  2100 
gm.  Regained  entrance  weight  fourteenth  day  in  hospital,  when  seventeen  days 
old.     Initial  loss   =  80  gm. 


Average  Daily  Gain  in  Grams. 

1  week  average  loss  per  day  =     9.28  gm.;  average    32.8    cal.  per  kilo. 

2  "            "        gain         "         =  11.42     "  "  82.5 

3  "           "           "           "         =  23.57     "  "        104.13 

4  "           "           "           "         =  15.7       "  "        100.2 

5  "           "           "           "         =  29.29     "  "        107.4 

6  "           "           "           "         =  14.27     "  "        114.7 

7  "           "           "           "        =  10.7       "  '•'        126.6 

8  "     (6  days)    "           "        =  16.66     "  "        122.6 


AVERAGE  HUMAN  MILK  DIETS 


195 


Fig.  120. — Baby  Grace  B.     Taken  at  admittance.     Birth  weight,  1395  gm. 


3000 
2800 
2000 
2400 

WEIGHT    9900 

GM-      2000 

1800 

1600 

1400 

600 
food       500 

c.C.        400 
300 

Hay                             June                                       July                                            August 

18 1019288588(1  S  C  9  18 15 18818187 SO  1    4   7  10131G19i->2Ji->31  1    4    7  101310198825 

\— 

,_ 

r 

— 

200 

100 

D 

1 

CALORIES  PER  KILO. 

l  1 

- 

- 

HJ 

'1 

ids-t 

&+ 

i 

i 

■•■ 

r 

ii 

:. 

II    * 

- 

Fig.  121. — Baby  Grace  B.  Weight  and  food  curves  and  calories  per  kilogram 
weight.  The  patient  entered  May  13.  Age,  one  day;  weight,  1440  gm.;  condition 
fair.  Discharged  August  27,  aged  one  hundred  and  six  days;  weight,  2960  gm. 
Showed  initial  gain  on  102  calories,  followed  by  a  loss  when  the  same  was  i 
below  100;  followed  by  a  gain  at  100,  and  a  steady  loss  at  91;  a  moderate  gain  at 
109;  the  loss  was  again  repeated  at  90.5  and  was  followed  by  a  rapid  gain  at  130 
to  137,  averaging  daily  24.5  gm.,  and  a  less  rapid  growth,  with  greater  fluctuations, 
at  115  to  109.5,  averaging  10  gm.  daily  and  again  rapidly  rising  with  124. 


196 


METHODS  OF  FEEDING 


Fig.  122. — Baby  Glenn.     Age,  two  days.     One  of  twins.     Other  twin  died  on  first 

day. 


V 

r  ^ 

|^                                                                                           \  1%  '• 

**    '"•■iiiiiii,  J                -V  _. 

N  - 

Fig.  J23, — Baby  Glenn.     Age,  one  hundred  and  eight  days, 


AVERAGE  HUMAN  MILK  DIETS 


197 


Fig.  124. — Baby  Glenn.     Age,  five  years. 


May         Juuc                                       July                                             August                                    Sept. 
nnrt#282029  1    1    7  10181619823598  1    1    7  10181010222523818   6  9  12151881212780  2    5   S 

3100 
2900 
2700 
2500 

WEIGHT     2300 

GM-       2100 

1900 

1700 

1500 

1300 

1100 

GOO 
500 

FOOD          400 

cc.        300 
200 
100 

— 1 

r- 

r— 

r^ 

rJ 

1 

CALORIES  PER  KILO. 

26 

:,.. 

96 

l.-io 

130 

140 

Hi;      H7, 

123     |     Ho     i;,o 

Fig.  125. — Baby  Glenn.  Weight  and  food  curves  and  calories  per  kilogram. 
Admitted  May  23;  weight,  1340  gm.  Discharged  September  8;  weight,  3245  gm., 
age,  one  hundred  and  eight  days.  Regained  entrance  weight  twenty-eighth  day 
in  hospital.     Initial  loss    =    155  gm.     Doubled   birth  weight  in  eighty-six  days. 


Average  Daily  Gain  in  Grams. 


1  week 

average  loss   per 

day  =     1.4 

2      " 

'          "           ' 

=     1.4 

3      " 

'        gain 

=     4.18 

4      " 

'           ' 

=  15.0 

5      " 

'           ' 

=  15.7 

G      " 

'           ' 

=  15.0 

7      " 

'           ' 

=  23.5 

8      " 

'           ' 

=  24.18 

9      " 

'           ' 

=  32.1 

10      " 

'           ' 

=  27.8 

11      " 

'           ' 

=  16.4 

12      " 

'           ' 

=  31.4 

13      " 

'           ' 

=  31.4 

14       " 

'           ' 

=  15.7 

15      " 

(3  days) 

'           ' 

=  15.0 

16      " 

(7d 

ays) 

'           ' 

'         =  24.2 

gm.;    average    25.1    cal.  per  kilo. 


55.8 
94.33 
115.0 
112.3 
125.9 
104.9 
1.V.I.7 
146.5 
147.9 
123.2 
136.7 
141.9 
135.8 
132.7 
143.3 


Fig.  126. — Baby  Ann  C.     Age,  eighteen  days. 


Fig.  127. — Baby  Ann  C.     Age,  one  hundred  and  thirty-six  days. 


ARTIFICIAL  FEEDING 


199 


May                        June                                     July                                           Jtncnii 

U172I>232C2!H    1    7  10l:(  lii  l'J222.">2*  1    1    7  10  1311. 1U22232S31  :l  «  !)  12  l.'ilH2l248Tt01   5   9  11 

3500 

3300 
3100 
2900 
2700 

WEIGHT 

™          2500 
GM. 

2300 

2100 

1900 

1700 

1500 

1300 
700 

FOOD          600 

M,ls       500 

cc-        300 

200 
100 

>-— — ^— — V 

<-n 

_ 

1 

r^ 

CALORIES  PER  KILO. 

20 

U) 

i:.i 

M 

51 

'■■' 

71 

; 

•", 

26 

1..LI 

Fig.  128. — Baby  Ann  C.  Weight  and  food  curves  and  calories  per  kilogram. 
Born  April  26,  Admitted  May  14;  weight,  1340  gm.  Discharged  September  9; 
weight  3265  gm.;  age,  one  hundred  and  thirty-six  days.     No  initial  loss. 

Average  Daily  Gain  in  Grams. 


1  week  average  gain  per  day  =  19.2  gm.; 


2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 


loss 
Standstill 


=  11.4 
=  24.1 
=  25.7 
=  27.0 
=  31.4 
=  22.8 
=  30.4 
=  42.8 
=  23.5 
=  27.9 
=  16.4 
=  10.0 
=  0.7 
=     2.0 


average  120.0  cal.  per  kilo. 

123.0  " 

122.7  " 

143.0  " 

159.0  " 

166.0  " 

135.0  " 

119.6  " 

140.5  " 

139.0  " 

180.0  " 

162.5  " 

140.6  " 
140.0  " 
129.6  " 
125.0  " 


ARTIFICIAL  FEEDING. 

There  can  be  no  comparison  between  the  results  to  be  expected 
in  feeding  premature  infants  on  human  milk  and  those  to  be  obtained 
with  artificial  food.  This  is  especially  true  of  infants  with  a  weight 
below  1500  gm.  Therefore,  if  it  becomes  necessary  to  resort  to 
artificial  feeding,  the  selection  of  a  food,  its  preparation,  and  its 
adaptation  to  the  infant  must  all  be  given  the  most  painstaking 


200  METHODS  OF  FEEDING 

consideration.  Many  varieties  of  artificial  diet  have  been  sug- 
gested by  many  different  authors,  such  as  simple  milk  dilutions 
cream  and  top-milk  mixtures,  skimmed  milk  and  buttermilk  prepa- 
rations, malt  soup  preparation,  condensed  and  evaporated  milk, 
etc.  The  results  with  these  various  diets  are  to  a  great  degree 
dependent  upon  the  physician's  intimate  understanding  and 
directions  for  the  use  of  the  individual  food  (Fig.  129). 


Fig.  129.— Utensils  needed  for  artificial  feeding:  Double  boiler  (small),  pan, 
funnel,  bottle-brush,  250-cc  (8-oz.)  graduated  glass  or  pitcher,  six  nursing  bottles 
and  rack,  paper  caps  for  bottles  (sterile) ,  nipples,  milk,  sugar,  flour,  milk  of  mag- 
nesia, citrate  of  soda,  tablespoon,  dairy  thermometer,  vegetable  mill. 

Quantity  of  Food.— It  must  be  remembered  that  the  figures  quoted 
for  the  feeding  on  breast  milk  are  the  maximum  that  can  be  assimi- 
lated and  are  excessive  quantities  for  artificial  feeding  in  the  first 
weeks  of  life  because  of  greater  difficulty  in  the  digestion  of  cows' 
milk.  These  infants  when  artificially  fed  must  at  all  times  be 
closely  watched  for  evidences  of  overfeeding,  and  the  first  evi- 
dence of  digestive  disturbances  or  of  intercurrent  infections  should 
lead  to  the  feeding  of  human  milk  whenever  possible. 

From  the  foregoing  statement,  it  is  quite  evident  that  smaller 
and  slower  weight  increase  may  be  expected  of  the  artificially  fed. 

Quality  of  Food.— As  previously  stated,  opinions  vary  greatly  as 
to  the  best  food  for  artificial  diet.  Most  clinicians  have  obtained 
the  best  results  with  the  feeding  of  low-fat  mixtures.  Boiled  milk, 
skimmed  milk  and  buttermilk,  with  carbohydrates  added,  are 
among  the  best. 

In  feeding  with  buttermilk  and  skimmed  milk  with  added  carbohy- 
drates, the  fat-free  mixtures  must  not  be  too  long  continued,  other- 
wise the  infants  will  suffer  from  fat  inanition.  By  the  end  of  the 
third  week  some  whole  boiled  milk  may  be  added  or  the  lactic-acid 
milk  should  be  prepared  from  partly  skimmed  milk.  It  is  our 
routine  to  boil  all  artificial  food  mixtures  for  at  least  two  minutes. 

In  feeding  with  a  buttermilk  high  carbohydrate  mixture,  the 
caloric  requirements  are  lower  than  in  feeding  with  the  full  milk 
(chymogen)  mixture  with  its  loiver  carbohydrate  content,  because 
the  energy  for  digestion  and  assimilation  requirements  are  lower 


ARTIFICIAL  FEEDING  201 

with  high-carbohydrate  low-fat  feeding  as  compared  with  high-fat 
low-carbohydrate  mixture. 

BUTTERMILK    AND    SKIMMED    MILK   MIXTURES. 

Buttermilk  or  skimmed  milk 1000 

Flour  (dextrinized) 10 

Sugar  (cane) 40 

The  above  being  used  for  the  first  weeks. 

Buttermilk  or  skimmed  milk 1000 

Flour  (dextrinized) 15 

Sugar  (cane) 60 

For  later  feedings. 

Maltose-dextrin  compounds  can  be  substituted  for  the  cane  sugar 
if  desired. 

Directions  for  Preparation.—  Add  the  flour  to  a  few  tablespoon- 
f  uls  of  buttermilk  or  skimmed  milk  and  rub  to  a  paste.  Add  butter- 
milk or  skimmed  milk  to  1  liter. 

Bring  mixture  to  a  boil  and  withdraw  from  the  fire. 

Add  the  sugar  and  bring  to  a  boil  for  the  second  time. 

This  process  should  require  about  twenty  minutes. 

Make  up  to  1  liter  with  boiled  water. 

Keep  on  ice. 
In  the  use  of  the  buttermilk  mixture  it  must  be  remembered  that 
infants  are  not  to  be  kept  on  this  low-fat  mixture  for  too  long  a 
time,  addition  of  whole  milk  being  indicated  after  the  first  few  weeks, 
beginning  with  one-third  whole  milk  and  two-thirds  skimmed ;  by  the 
fourth  week  equal  parts  whole  and  skimmed  milk  should  be  used  in 
the  preparation  of  the  lactic  acid  milk. 

Chymogen  Mill:. 

Requirements  for  Preparation. 

Milk. 

Single  boiler,  1-  or  2-quart. 

Dairy  thermometer. 

Chymogen  powder  (Armour  &  Co.). 

Teaspoon. 

Egg  beater. 
Directions  for  Preparation.— Boil  milk  for  five  minutes  over 
direct  flame,  cool  to  104°  F.,  and  add  one  full  teaspoonful  of  chy- 
mogen to  each  quart  of  milk,  and  stir  for  one-half  minute.  Let  it 
come  to  a  clabber  by  allowing  it  to  stand  for  fifteen  minutes, 
holding  it  as  near  100°  F.  as  possible  by  keeping  it  in  a  warm  place; 
then  beat  it  well  until  the  curd  is  finely  divided.     Put  it  in  indi- 


202  METHODS  OF  FEEDING 

vidual  feeding  bottles  and  place  on  ice.  Do  not  heat  above  100°  F. 
when  preparing  individual  bottles  for  feeding,  otherwise  curds  will 
clump  and  will  not  pass  through  the  nipple.  Reheating  is  best 
accomplished  by  placing  the  individual  feeding  bottle  in  a  cup  of 
warm  water  not  over  115°  F.  and  allowing  it  to  stand  for  ten  minutes. 
Replenish  the  warm  water  if  necessary. 

We  have  found  this  predigestion  of  boiled  milk,  by  the  addition 
of  rennet  (chymogen)  assures  the  infant's  stomach  of  a  fine,  floccu- 
lent  curd,  which  is  about  the  size  of  that  of  human  milk.  In 
beginning  feedings  with  the  above  preparation  it  is  usually  diluted 
with  3  parts  of  water  and  increases  in  quality  made  as  indicated, 
and  the  quantity  increased  as  in  the  feeding  of  human  milk.  In 
feeding  with  tjie  diluted  predigested  milk,  15  gm.  (§  ounce)  of 
lactose  should  be  added  to  each  liter  during  the  first  few  days,  and 
the  amount  gradually  increased  to  30  gm.  (1  ounce).  When  chy- 
mogen is  not  available,  whole  milk  boiled  for  five  minutes  may  be 
used. 

In  the  feeding  of  these  food  mixtures  the  relative  caloric  values 
of  the  mixtures  as  compared  with  breast  milk  must  be  borne  in 
mind,  otherwise  inanition  will  be  the  result. 

Human  milk  equals  700  calories  per  liter  or  21  per  ounce. 

Skimmed  milk  or  buttermilk  mixture  containing  10  gm.  dextri- 
nized  flour  and  40  gm.  sugar  per  liter  equals  16  calories  per  ounce 
or  525  per  liter. 

Chymogen  milk  (whole  milk)  equals  700  per  liter  or  21  per  ounce. 

Chymogen  milk  when  diluted  with  3  parts  water  and  15  gm.  of 
sugar  per  liter  equals  235  calories  per  liter  or  7  per  ounce. 

Chymogen  milk  when  diluted  with  equal  parts  water  and  30  gm. 
of  sugar  per  liter  of  mixture  equals  470  per  liter  or  14  per  ounce. 
Each  individual  ounce  of  sugar  per  liter  of  mixture  increases  its 
food  value  by  4  calories  per  ounce.  Rarely  should  more  than  2 
ounce  of  sugar  be  added  for  each  liter  of  the  mixture,  which  repre- 
sents an  addition  of  8  calories  (6.5  per  cent)  of  carbohydrate  to  that 
already  contained  in  the  milk.  It  is,  therefore,  of  the  greatest 
importance  that  the  milk  itself  either  skimmed,  buttermilk  or  whole 
be  increased  gradually  along  with  the  sugar. 

Amounts  to  be  Fed.— Depending  upon  the  weight  and  develop- 
ment of  the  infant,  the  tables  as  given  for  human  milk  feeding 
should  be  followed.  It  must  be  remembered  that  while  the  artificial 
diets  recommended  have  a  lesser  caloric  value  per  cc  than  human 
milk,  they  represent  for  most  infants  the  maximum  capacity  for 
digestion  and  assimilation.  Of  necessity,  lesser  weight  increases 
and  slower  progress  are  to  be  expected.  The  infants  are  paler, 
tissue  turgor  is  lacking  and  they  are  less  immune  to  infection. 


ARTIFICIAL  FEEDING  203 

Other  Dietetic  Requirements.— To  counteract  the  effects  of  boiling, 
orange-juice  feeding  should  be  instituted  by  the  third  week, 
beginning  with  0.5  cc  (8  drops)  and  increasing  2  to  4  cc  (^  to  1  dr.  I 
daily  by  the  eighth  week,  in  order  to  avoid  scurvy.  Cod-liver  oil 
as  an  antirachitic  should  be  fed  by  the  fourth  week,  beginning 
with  0.5  cc  (8  drops)  daily  divided  into  two  feedings  and  increased 
to  2  cc  (30  drops)  daily  by  the  eighth  week.  It  may  be  mixed 
with  the  orange  juice.  To  counteract  the  low  iron  content  of  these 
diets,  carbonate  of  iron  in  0.03  gm.  (gr.  |)  or  citrate  of  iron  and 
ammonia  in  0.03  gm.  (gr.  \)  once  daily  should  be  started  by  the 
fourth  week.     The  latter  may  be  prescribed  in  solution. 

Mixed  Diet.— These  food  additions  apply  for  breast-fed  as  well  as 
bottle-fed  infants. 

Fifth  month,  a  little  well-cooked  cereal  may  be  added  to  one  of 
the  meals  (begin  with  one  teaspoonful) ,  adding  it  to  the  bottle  of 
milk. 

At  the  sixth  month,  infants  readily  take  a  broth  and  vegetable 
meal  as  a  substitute  for  one  of  the  milk  feedings,  in  the  form  of 
a  vegetable  and  meat  soup.  Begin  with  one  ounce  and  follow  by 
a  second  bottle  containing  the  milk  mixture  with  one  ounce  less 
than  full  feeding.     Gradually  replace  an  entire  milk  feeding. 

Ninth  month,  a  vegetable  soup  or  a  clear  broth  (chicken,  lamb 
or  veal),  and  toast  or  zwieback  crumbs,  with  an  additional  portion 
of  stewed  fruits  (apples,  prunes)  or  a  strained  vegetable  (spinach, 
carrots  or  turnips) .  The  broth  is  usually  given  in  the  same  quantity 
as  the  bottle,  if  given  alone,  or  somewhat  less  if  either  the  vegetable 
or  fruit  is  given  in  addition. 

Cereal.     ■ 

Two  tablespoons  of  cereal. 

One-half  pint  of  water  and  one-half  pint  of  milk. 

One  pinch  of  salt. 

Cook  in  double  boiler  for  one  hour. 

Begin  feeding  one  and  a  half  tablespoonful,  gradually  increasing 
to  two  tablespoonfuls. 

Add  the  cereal  to  the  milk  mixture  or  pour  part  of  bottle  over 
the  cereal  and  feed  with  a  spoon.  Finish  the  meal  with  remainder 
of  the  bottle. 

Toast  or  zweiback  (one-half  slice  crumbed)  at  about  the  eighth 
month. 

Vegetable  Soup. 

Lean  lamb  cut  into  small  pieces  (f  lb.). 
One  potato. 
One  carrot. 


204  METHODS  OF  FEEDING 

Two  stalks  of  celery. 

One  tablespoonful  of  pearl  barley. 

Two  tablespoonfuls  of  rice. 

Two  quarts  of  water. 

One  pinch  of  salt. 

Finely  divide  the  vegetables.  Add  the  vegetables  barley  and 
rice  to  two  quarts  of  water.  Boil  down  to  one  quart,  cooking 
three  hours.     Add  pinch  of  salt.     Pass  through  fine  sieve. 

Begin  feeding  one  ounce,  gradually  increasing  to  eight  ounces, 
cutting  out  an  ounce  of  milk  mixture  for  each  ounce  of  soup  given. 

When  less  than  a  full  feeding  is  fed  finish  the  meal  with  sufficient 
milk  mixture,  from  a  second  bottle,  to  make  a  full  feeding. 


CHAPTER  IX. 
INCUBATORS. 

The  History  of  Incubators.— The  first  records  of  the  use  of  incuba- 
tors are  found  in  description  of  their  employment  for  the  hatching 
of  eggs  of  fowls  in  Alexandria,  and  it  is  possible  that  it  may  have 
occurred  to  the  Egyptians  to  apply  this  method  to  the  new  horn. 
One  cannot,  however,  assume  this,  for  no  author  of  that  period  has 
mentioned  it.  Hippocrates,  in  his  writings  of  460  B.C.,  makes  the 
following  statement:  "No  fetus  coming  into  the  world  before 
the  seventh  month  of  pregnancy  can  be  saved."  We  note  that  the 
literature  of  our  day  records  only  a  limited  number  of  exceptions  to 
these  conclusions  that  infants  born  before  the  end  of  the  twenty- 
eighth  week  are  viable. 

Pasquad  quotes  a  thesis  of  the  Eleventh  Century  of  the  Republic 
wherein  the  author,  Rudellet,  writing  on  the  vitality  of  infants, 
reports  the  following  which  we  think  well  worth  citing.  He  quotes 
from  Baillet  (  Decisions  of  Savants,  Paris,  1722)  as  follows :  "  Among 
the  records  of  celebrated  children  Baillet  reports  that  of  Fortunio 
Liceri,  whose  mother  gave  birth  to  him  long  before  the  ordinary 
time  during  the  fatigue  and  shocks  of  a  sea  voyage.  This  fetus 
was  no  larger  than  the  palm  of  your  hand,  but  his  father  who  was 
a  physician,  having  examined  it,  had  carried  it  to  the  place  which 
was  to  be  the  end  of  his  voyage.  There  he  had  other  physicians 
see  it.  They  found  that  there  was  lacking  nothing  essential  to 
life,  and  his  father  undertook  to  finish  Nature's  task  and  to  work 
at  the  formation  of  the  child  with  the  same  skill  that  men  exhibited 
in  hatching  chickens  in  Egypt.  He  instructed  a  nurse  in  all  that 
she  had  to  do  in  the  maintaining  of  exactly  measured  artificial 
heat  and  the  requirements  for  his  general  care  and  feeding.  He 
lived  to  be  seventy-nine  years  of  age  and  distinguished  himself  in 
science  by  a  large  number  of  works." 

This  is  a  tale  the  recording  of  which  leads  us  to  believe  that 
use  was  made  of  the  knowledge  of  the  methods  used  at  that  age  in 
incubating  fowls.  We  will  dispense  with  any  remarks  and  will 
content  ourselves  with  mentioning  the  fact,  in  citing  the  reflection 
of  the  historian  himself:  "One  must  admit,"  says  the  author  in 
concluding  the  narrative  of  which  we  have  just  given  the  analysis, 
"  that  all  which  is  unbelievable  is  not  always  false,  and  that  proba- 
bility is  not  always  on  the  side  of  truth," 


206 


INCUBATORS 


Little  is  recorded  from  1722  to  1857,  the  time  when  Denuce 
described  his  incubator.  Modern  French  writers  attribute  the 
origin  of  the  first  incubator  for  infants  to  Denuce,  of  Bordeaux, 
who  in  1857  described  his  model  which  consisted  of  a  double-walled 
tub  which  was  to  be  filled  with  warm  water  at  intervals  (Fig.  130). 

Clementovsky  states  that  a  somewhat  similar  contrivance  was 
used  by  Riihl  in  St.  Petersburg  as  early  as  1835. 

Crede,  in  1866,  published  the  results  which  he  obtained  with  a 
similar  apparatus  which  had  been  in  use  in  his  clinic  in  Leipzig 
since  1860,  with  the  use  of  which  he  was  able  to  lower  his  mortality 
by  18  per  cent.  This  simple  tub  has  been  modified  by  some  of  the 
continental  clinicians  by  putting  it  on  a  stand  and  providing  it 
with  a  hose  attachment  for  connection  with  a  hot-water  faucet 
(Fig.  131). 


Fig.  130. 


-Warm  tub  with  double  wall  jacket.     First  used  by  Denuce  in  1857  and 
Crede  in  1860. 


In  1879  Winckel  described  a  permanent  bath  in  which  the  infant 
floated.  This  apparatus  was  an  attempt  at  imitating  intra-uterine 
conditions,  but  needless  to  say,  because  of  the  danger  of  drowning 
and  infection,  it  proved  unpopular.  The  water  in  this  tub  was 
kept  between  36°  and  38°  C. 

In  1680  Tarnier  had  an  infant  incubator  constructed  similar  to 
those  used  as  chicken  incubators.  This  incubator  was  built  for 
him  by  Odile  Martin,  director  of  the  Paris  Zoo,  and  was  built  of 
such  size  that  it  could  hold  several  children;  and  was  installed  in 
the  Maternity  Hospital  of  Paris  in  1881  (Fig.  132). 

This  is  the  first  closed  incubator  which  may  be  qualified  as 
modern,  for  the  perfected  apparatus  of  our  day  differs  from  it  only 
in  detail. 

This  is  the  time  that  dates  the  principal  work  undertaken  on 
incubator  construction,  and  the  most  varied  modifications  have 
followed  each  other  almost  without  interruption  until  our  day. 


THE  HISTORY  OF  INCUBATORS 


207 


The  first  important  work  on  the  results  obtained  by  their  use 
is  an  account  by  Auvard  in  1883.     In  this  interesting  work  the 


Fig.  131. — Modified  warm  tub. 


Fig.  132. — Tarnier  incubator. 


author  gives  the  first  statistics  on  the  use  of  the  incubator  in  the 
Maternity  in  this  period  under  the  scientific  direction  of  Tarnier. 


208  INCUBATORS 

Berthod,  an  interne  of  Tarnier,  in  an  excellent  thesis  (1887), 
continued  this  study,  adding  thereto  some  new  data  on  the  condi- 
tions indicating  the  use  of  an  incubator  for  the  new-born  infant. 
His  statistics  are  still  most  imposing,  and  they  treat  upon  almost 
a  thousand  cases  in  which  the  incubator  was  used.  Among  the 
most  influential  of  these  was  Budin.11 

The  monographs  of  Auvard  and  Berthod  are  the  only  two  import- 
ant early  works  treating  of  the  study  of  incubators  and  the  results 
of  their  use.  Their  work  shows  the  importance  of  the  prevention  of 
hypothermia,  and  they  lay  particular  stress  upon  the  protection 
of  the  infant  from  the  moment  of  its  birth.  It  may  be  stated  with 
justice  that  the  early  progress  in  the  care  of  premature  infants  was 
to  a  great  extent  influenced  by  the  interest  of  the  French 
obstetricians  in  the  care  of  these  infants. 

Since  then  a  large  number  of  authors  have  written  on  this  subject, 
but  it  is  rather  to  modify  certain  details  or  to  propose  new  forms 
of  apparatus  than  to  give  new  rules. 

From  that  time  on  until  our  day  the  incubator  has  undergone 
changes— some  quite  radical,  while  some  have  remained  as  rudi- 
mentary as  when  first  originated. 

Only  those  models  demonstrating  more  important  changes  and 
improvements  will  be  described. 

Hearson  introduced  automatic  temperature  regulation  within  the 
incubator.  His  apparatus  was  so  constructed  as  to  set  off  an 
electric  alarm  clock  when  the  maximum  temperature  desired  was 
past.  This  apparatus  was  modified  by  Eustache  who  attempted 
to  attach  automatic  gas  or  oil-heating  apparatus  to  the  so-called 
"thermostat  nurse  of  Hearson." 

In  1896  Diffre,  of  Montpelier,  and  Lion  built  metal  incubators, 
providing  for  what  they  termed  final  perfection  which  provided  for 
automatic  heating  through  thermostat  control,  the  heat  being 
furnished  through  a  hot-water  system  heated  by  an  oil  or  gas  stove 
at  the  side  of  the  incubator.  In  this  incubator  refinements  in 
ventilation  and  control  of  humidity  were  introduced. 

A  giant  incubator  was  prepared  by  Prof.  Pajot,  in  1885,  for  use 
in  his  clinic,  consisting  of  a  large  heated  chamber,  practically  an 
oven;  the  congenitally  feeble  infants,  entirely  separated  from  their 
mothers,  being  fed  and  tended  by  wet-nurses. 

Budin,  in  stating  the  disadvantage  of  the  Pajot  apparatus,  said: 
"The  wet-nurses  were  obliged  to  feed  and  tend  the  infants  in  this 
oven;  and  the  mothers,  separated  from  their  infants,  soon  lost  all 
interest  in  those  whom  they  were  unable  to  nurse  and  cherish.  It 
is  better  by  far  to  put  the  little  one  in  an  incubator  by  its  mother's 
bedside." 

Prof.  Hutinel,  of  Paris,  whose  studies  on  the  subject  are  of 


THE  HISTORY  OF  INCUBATORS 


209 


interest,  constructed  a  couveuse  composed  of  a  boat-like  vessel  of 
enameled  crockery  whose  bottom  was  replaced  by  a  plate  of  gal- 
vanized  sheet-iron  pierced  by  holes.  The  plate  served  as  a  cover 
to  a  metal  box,  which  contained  three  bowls  filled  with  hot  water. 
The  top  of  the  apparatus  was  closed  by  a  heavy  glass  which  could 
be  raised  to  a  desired  degree  by  the  aid  of  a  screw,  and  which  allowed 
the  airing  of  the  box.  The  water  bowls  were  replenished  every  two 
or  three  hours  to  maintain  the  temperature.  The  crockery  tub 
could  be  disinfected  with  ease  by  wiping  it  with  a  cloth  saturated 
with  bichloride  of  mercury  solution,  which  was  its  best  feature. 


Fig.  133.— Finkelstein  incubator. 


Simple  and  cheap  in  its  operation  is  Finkelstein's  incubator. 
The  essentials  of  its  construction  may  be  seen  from  the  accompany- 
ing illustration  (Fig.  133).  The  circular  holes  in  the  side  walls  of 
the  box  for  inserting  hot-water  vessels  also  serve  as  inlets  for  the 
incoming  air,  while  the  used  air  escapes  through  the  holes  at  the 
upper  part  near  the  cover. 
14 


210 


INCUBATORS 


Rommel's  apparatus  proved  to  be  good  and  is  at  the  same  time 
like  the  latter  easily  carried  from  one  place  to  another  (Fig.  135). 
The  chamber  is  0.83  cubic  meter  large,  enclosed  on  three  sides  by 
mirror  glass,  the  corner  being  rounded  to  facilitate  cleaning.  The 
ventilating  shaft  permits  the  air  to  be  renewed  100  to  120  times 
every  hour.  The  humidity  regulation  is  simple.  The  large  supply 
of  hot  water  of  about  15  to  20  liters  permits  a  pretty  constant 
temperature,  the  fluctuations  according  to  Rommel  being  less  than 
1°.     For  heating  electric  incandescent  lamps  are  used. 


Fig.  134.  —  Reinach  heated  bed. 


Moll's  incubator  (Fig.  138)  distinguishes  itself  by  the  fact  that 
the  head  of  the  infant  remains  outside  the  warm  box  and  breathes 
the  air  of  the  room,  this  having  a  great  advantage  for  respiration  of 
debilitated  infants,  since,  because  of  stronger  respiratory  stimulus, 
attacks  of  asphyxia  may  be  more  easily  avoided. 

To  this  class  of  incubators,  which  are  all  modifications  of  the 
origional  Lion  type,  belong  the  models  of  Couney,  DeLee  and  others 
now  on  the  market  in  the  United  States  (Fig.  136  and  137). 

These  models  differ  but  slightly  in  principle,  the  chief  variation 
being  in  the  maimer  of  heating  and  distributing  the  air  and  supply- 
ing moisture.  They  may  be  heated  by  gas  or  oil  stoves  situated 
at  the  side  of  the  incubator,  heating  the  air  as  it  enters,  or  by  a 


THE  HISTORY  OF  INCUBATORS 


211 


system  of  electric  bulbs  within  the  incubator.  In  the  latter  models 
the  bulbs  are  usually  located  either  in  the  floor  or  sides.  The  best 
models  are  those  in  which  the  heating  system  is  modelled  after  that 
used  in  hot-water  heating  plants  for  houses.  The  temperature  is 
automatically  controlled  by  a  thermostat. 

A  thermometer  is  fastened  near  the  side  window,  so  that  it  may 
be  easily  read,  and  a  hygrometer  is  used  to  indicate  the  degree  of 
moisture. 


Fig.  135. — Rommel  incubator. 


This  type  of  incubator  has  in  the  past  ten  years  lost  considerable 
of  its  early  popularity,  as  is  evidenced  by  a  visit  to  most  of  the 
large  hospitals.  A  great  deal  of  this  deserved  unpopularity  is  due 
to  the  inability  to  ventilate  them  in  the  ward  and  the  necessity  for 
furnishing  a  trained  attendant.  To  properly  supply  these  incuba- 
tors with  a  free  current  of  air  it  is  necessary  to  connect  them  so 


212  INCUBATORS 

that  they  will  receive  a  supply  of  air  from  outside  of  the  building. 
To  counteract  the  tendency  to  an  insufficient  air  current  in  the 
absence  of  winds  or  when  they  are  in  the  wrong  direction  an  electric 
fan  should  be  incased  on  the  outside  of  the  building  in  such  posi- 


Fig.  136. — Lion-type  incubator  (Couney  model).     The  fresh  air  is  forced  through  a 
large  air-shaft  by  an  electric  fan  on  the  outside  of  the  building. 

tion  that  air  may  be  blown  directly  through  the  incubator.  This 
is  difficult  of  arrangement  when  the  incubators  are  located  above 
the  first  floor  of  the  building.  When  the  station  is  located  on  the 
first  floor  it  is  necessary  to  avoid  the  dampness  and  dust  of  the 
street  level,  and  this  can  be  accomplished  by  installing  a  large 


THE  HISTORY  OF  INCtfBATORS 


213 


funnel  15  or  20  feet  above  the  ground  level,  some  24  to  36  inches 
in  diameter,  to  which  is  attached  a  10-inch  stack  which  can  be 
connected  with  a  cage  at  its  base  in  which  the  electric  fan  is  installed. 
From  this  point  the  air  is  blown  through  the  system  of  incubators. 


Fig.  137. — Lion-type  incubator.       I  »eLee  model.) 


When  such  a  considerable  quantity  of  air  is  blown  into  the  incu- 
bator system,  it  becomes  necessary  to  filter  it  through  several  layers 
of  cotton.     This  is  best  done  at  the  side  of  the  individual  incubator. 

The  Cincinnati  Hospital  uses  an  electrically  heated  bassinette. 


214 


INCUBATORS 


The  temperature  is  regulated  by  a  series  of  electric  lamps  under 
the  mattress.     The  apparatus  consists  of  a  double  wall  frame,  with 


Fig.  138.— Moll  heated  bed. 


Fig.  139. — Hess  water-jacketed  infant  bed. 


THE  HISTORY  OF  INCUBATORS 


215 


hot  air  rising  in  this  double  wall  and  escaping  through  small  holes 
near  the  top  which  can  be  opened  or  closed  as  may  be  required  by 
a  slide  damper. 

In  1914  the  writer  designed  an  electric  heated  water-jacketed 
infant  bed. 

It  combines  the  double-wall  water  jacket  with  insulation  to  pre- 
vent external  loss  of  heat,  and  electric  heating  by  a  large  plate  with 
rheostat  control. 


Fig.  140.— Cross-section  of  Hess  heated  bed.  1,  Cooper  wall  covering  asbestos 
layer;  2,  asbestos  layer  insulating  water-jacket;  3,  4,  copper  walls  covering  water- 
jacket;  5,  water  surrounding  side  and  floor  of  bed;  6,  water  glass;  7,  funnel  for 
filling  jacket;  8,  cock  for  emptying  jacket;  9,  removable  crib;  10,  air  space  under- 
neath crib;    11,  electric  heating  plate;    12,  rheostat;    13,  electric  plug. 

For  hospital  and  home  equipment  the  bed  answers  many  require- 
ments, because  of  its  simplicity  of  operation  in  any  well-ventilated 
and  moderately  heated  room. 

It  can  be  used  for  the  care  of  premature  infants,  for  the  protec- 
tion of  the  new-born  full-term  infant  immediately  after  delivery 
and  for  infants  suffering  from  hypothermia  from  other  causes. 

This  bed  fulfils  the  following  needs  of  the  infant:  (1)  Safety. 
The  maximum  temperature  which  can  be  obtained  within  the  bed 
is  about  110°  F.  when  the  lid  and  canopy  are  in  place  with  a  room 
temperature  of  70°  F.     While  such  a  temperature  would  be  injurious 


210 


INCUBATORS 


if  maintained  for  a  long  period  of  time,  such  surroundings  if  tempo- 
rary can  cause  but  little  injury.  (2)  Simplicity  of  operation.  It 
requires  practically  no  attention  unless  there  are  extreme  ranges 
of  temperature  within  the  ward,  since  the  asbestos  insulation  pre- 
vents radiation  from  the  outer  surface  of  the  bed  and  the  heater 
holds  the  water  at  a  constant  temperature.  (3)  Ventilation.  This 
apparatus  assures  the  baby  of  an  adequate  supply  of  fresh  air  if 
placed  in  an  ordinary  room  which  is  well  ventilated.     (4)  Humidity 


Fig.  141. — Cross-section  of  Hess  bed  showing  direction  of  air  currents. 


is  maintained  at  nearly  the  same  degree  as  the  surrounding  air 
because  of  the  almost  constant  change  of  air  within  the  bed  and 
moisture  supplied  by  an  evaporation  pan  beneath  the  crib.  (5) 
It  is  easily  cleaned  and  disinfected. 

The  construction  of  the  bed  is  such  that  it  can  be  used  in  an 
ordinary  ward  or  room,  giving  the  infant  the  advantage  of  a  most 
perfect  room  ventilation. 

The  following  suggestions  will  aid  in  the  practical  application  of 
this  bed  for  use  in  hospitals  or  the  home. 


THE  HISTORY  OF  INCUBATORS  217 

A  special  room  should  lie  provided.  This  has  a  practical  advan- 
tage as  it  impresses  the  nurses  to  consider  this  room  as  barriered. 
This  will  make  a  demand  upon  the  nursing  staff  for  observation  of 
all  of  the  rules  of  aseptic  nursing. 

This  room  should  he  supplied  with  an  ample  system  of  heating 
coils  controlled  by  a  thermostat  for  winter  use,  thereby  facilitating 
the  maintenance  of  a  more  or  less  stable  temperature  in  the  room 
which  should,  in  so  far  as  possible,  range  between  (>8  and  75°  F. 

The  temperature  within  the  room  and  bed  should  be  read  and 
charted  at  six-hour  intervals,  best  at  G  a.m.,  12  M.,  and  G  and  12  p.M. 
as  the  most  likely  time  for  maximum  changes  in  the  ward  tempera- 
ture. 

Ventilation  should  be  adequate  but  not  excessive,  and  the  room 
should  be  so  constructed  that  the  beds  may  be  placed  without 
the  line  of  direct  air  currents.  This  is  accomplished  by  having  the 
ventilating  windowrs  and  transoms  on  one  side  of  the  room,  while 
the  opposite  side  is  built  with  non-ventilating  windows  or  blank 
walls  at  either  end. 

Humidity  in  so  far  as  the  room  is  concerned  will  require  little 
attention  except  at  such  time  when  considerable  artificial  heating 
is  necessary.  To  supply  the  needed  moisture  during  cold  weather 
when  ventilation  of  the  room  is  more  or  less  limited,  a  large  eva] to- 
rating  pan  should  be  in  direct  contact  with  the  radiator  coils. 
When  these  means  fail  to  furnish  the  desired  moisture,  a  wet 
sheet  may  be  hung  in  the  room  and  remoistened  as  indicated  by 
the  hygrometer. 

In  so  far  as  possible  the  relative  humidity  should  be  kept  at 
about  55  per  cent.  However,  amounts  less  than  this  down  to 
45  per  cent  will  usually  cause  little  or  no  discomfort  or  retardation 
of  progress.  It  has  been  our  experience  that  with  a  good  free 
ventilation  through  open  transoms  or  windows  when  the  tempera- 
ture of  the  room  does  not  exceed  80°  F.,  the  normal  water  content 
of  the  air  is  quite  sufficient  and  little  or  no  attempt  at  influencing 
the  room  humidity  is  necessary.  However,  this  will  not  answer 
the  purpose  where  a  closed  room  is  used. 

When  a  special  room  cannot  be  provided  the  beds  for  well  pre- 
matures should  be  kept  in  the  nursery  used  for  normal  infants. 
They  must  never  be  brought  into  contact  with  infected  infants 
because  of  the  danger  of  crossed  and  mixed  infections.  Neither 
should  infected  prematures  be  placed  among  well  new-born  infants. 

All  infants  should  be  removed  from  this  room  to  the  nurserj 
once  daily,  so  that  it  may  be  thoroughly  ventilated  and  cleaned 
by  the  use  of  soap  and  water.  Before  replacing  the  infants  the 
air  should  be  reheated  to  remove  excessive  humidity. 


218  INCUBATORS 

CARE  OF  THE  BED. 

General  Care.— Once  daily  the  infant  should  be  removed  from 
the  bed  to  allow  of  cleaning  the  interior  with  a  damp  cloth.  This 
is  best  done  at  the  time  of  renovating  the  room.  The  crib  itself 
should  also  be  wiped  with  a  damp  cloth.  All  linens  should  be 
changed  at  least  once  daily  and  at  other  times  when  soiled.  Extra 
mattresses  should  be  supplied  so  that  they  may  be  given  an  airing 
on  alternate  days  and  a  thorough  renovating  as  frequently  as 
soiled.  Renovation  is  imperative  between  cases.  Mattresses 
should  be  protected  by  rubber  sheeting.  A  thick  pad,  however, 
must  be  placed  between  the  rubber  sheeting  and  the  infant. 

The  heating  apparatus  consists  of  a  plate  with  a  6-inch  surface 
in  direct  contact  with  the  floor  of  the  water  jacket,  and  especially 
constructed  to  carry  a  maximum  capacity  of  300  Watts,  which 
makes  it  impossible  to  heat  the  water  above  155°  F.  and  the  interior 
of  the  bed  above  110°  F.  at  a  room  temperature  of  70°  F. 

A  rheostat  with  seven  contacts  is  fastened  to  the  standard. 
Six  of  them  are  graduated  to  take  current  varying  from  25  Watts 
on  contact  1  to  300  Watts  6n  contact  6.  The  first  contact  shuts 
off  the  current. 

For  the  protection  of  very  frail  infants  a  partial  cover  for  the 
tub,  21|  inches  in  length,  is  provided  to  shield  them  more  com- 
pletely from  outside  air  currents.  It  is  provided  with  a  ther- 
mometer, so  that  the  temperature  within  the  tub  can  be  ascertained 
by  the  nurse  at  all  times.  Further,  a  brass  nickel-plated  frame 
covered  by  a  removable  linen  cover  is  provided  in  the  form  of  a 
hood.  This  can  be  set  over  the  open  space  not  covered  by  the 
metal  lid  in  case  of  great  air  currents  and  extremely  cold  nights. 
This  allows  a  free  circulation  of  air  to  enter  at  the  front  of  the 
canopy  while  at  the  same  time  preventing  direct  downpour  of  cold 
air  onto  the  infant's  head.  The  hood  raises  the  temperature 
within  the  bed  on  an  average  of  from  5°  to  10°  F.,  depending  on 
the  room  temperature  and  current  used,  but  does  not  interfere 
with  perfect  ventilation.  The  hood  is  made  collapsible,  and  may 
be  set  at  any  angle  desired,  as  may  be  indicated. 

The  hood  is  used  in  combination  with  the  lid  for  very  small  or 
frail  infants  where  a  high  temperature  is  desired  or  when  the  room 
temperature  is  more  or  less  beyond  our  control,  because  of  a  defec- 
tive heating  system  or  extremely  cold  weather.  Both  are  used 
when  it  is  desired  to  heat  this  bed  rapidly  in  an  emergency. 

The  removable  metal  lid,  which  also  holds  the  thermometer  for 
temperature  reading,  is  used  alone  for  most  cases,  the  length  of 
time  varying  from  a  few  days  to  several  weeks.  The  hood  and 
lid  are  both  left  off  for  the  more  mature  cases  and  those  being 


CARE  OF  THE  BED  219 

prepared  for  graduation  from  the  heated  bed  to  the  nursery  or 
home. 

With  the  lid  on  it  is  rarely  necessary  to  pass  contact  4  of 
the  rheostat  to  obtain  a  temperature  of  90°  F.  in  a  room  approxi- 
mating a  temperature  of  70°  F.  When  it  is  desired  to  heat  the 
bed  rapidly  preparatory  to  its  use,  the  rheostat  may  be  set  at  point 
(i  with  the  hood  and  lid  on  until  the  bed  is  heated  to  the  tempera- 
ture that  may  be  needed  when  it  may  be  returned  to  points  2,  3 
or  4,  depending  upon  the  fetal  age  and  development  of  the  infant. 

As  the  infant  develops  it  should  be  gradually  prepared  for  gradu- 
ation from  the  incubator  by  lowering  the  temperature  of  the  bed 
by  degrees  to  that  of  the  room  temperature.  This  may  cover  a 
period  of  several  days  or  weeks.  At  this  time  the  lid  may  be 
removed.  We  have  found  it  of  advantage  to  remove  the  lid  of 
the  bed  when  the  infant  has  developed  sufficiently  to  thrive  in 
the  room  temperature  of  75°  F.,  after  which  the  temperature  of 
the  bed  with  the  lid  off  can  be  left  a  few  degrees  above  the  room 
temperature  by  advancing  the  rheostat  by  one  or  two  points. 
The  temperature  of  the  bed  is  now  measured  by  placing  a  ther- 
mometer alongside  of  the  baby  within  the  sleeping  bag  or  under 
the  blanket. 

It  is  our  custom  to  cover  the  infant  when  in  the  bed  with  a 
light  sleeping  bag  or  light  woolen  blanket,  in  order  to  more  com- 
pletely stabilize  its  body  temperature,  as  our  beds  are  kept  in  a 
well- ventilated  room.  The  sleeping  bag  should  either  be  fitted 
with  a  flap,  which  can  be  used  as  a  hood  or  a  small  bonnet  should 
be  worn  or  the^blanket  should  be  so  applied  so  that  it  can  be  used 
as  a  head  cover.  Outer  garments  or  covers  should  be  applied  loosely 
so  as  to  allow  of  free  movements  of  the  extremities. 

In  order  to  use  the  bed  rationally  it  is  necessary  to  have  an  idea 
of  the  effect  of  the  various  factors  influencing  the  crib  temperature. 
To  this  end  the  following  observations  are  offered  for  the  guidance 
of  the  attendant. 

COMPARATIVE    MEASUREMENTS    OF   TEMPERATURE    IN    HEATED    BED 
UNDER  DIFFERENT   CONDITIONS. 

The  temperature  as  read  from  the  lid  thermometer  and  that  of 
a  thermometer  placed  alongside  of  the  infant  under  a  light  blanket 
used  as  a  cover  will  show  variations  which  rarely  exceed  1  to  3°  F. 

At  a  room  temperature  varying  between  70°  and  80°  F.  The  lid 
temperature  will  approximate  the  following: 

bid  and  Canopy  On.— 10°  F.  above  the  room  temperature  when 
on  contact  2;  15°  F.  above  the  room  temperature  when  on  contact 
3;    20°  F.  above  the  room  temperature  when  on  contact  4;    25°  F. 


220 


INCUBATORS 


above  the  room  temperature  when  on  contact  5;  30°  F.  above  the 
room  temperature  when  on  contact  (). 

Lid  On  and  Canopy  Off.— 5°  to  10°  F.  above  the  room  tempera- 
ture when  on  contact  2;  10°  F.  above  the  room  temperature  when 
on  contact  3;  15°  F.  above  the  room  temperature  when  on  contact 
4;  20°  F.  above  the  room  temperature  when  on  contact  5;  25°  F. 
above  the  room  temperature  when  on  contact  (i. 

Lid  and  Canopy  Off.— The  temperature  alongside  of  the  infant 
under  its  blanket  will  average  from  5°  to  10°  F.  higher  than  the 
room  temperature  on  contacts  2,  3,  4,  5  and  6  with  a  room  tempera- 
ture between  70  to  80°  F. 

As  in  all  other  care  of  these  infants  individualization  should  be 
the  watchword  and  only  by  a  careful  observation  of  weather  and 
temperature  changes  can  the  best  results  be  obtained. 


September                                                                                                                           October 
1       3       5       7       9,      11     IS    15     17,19     21     23     35    27      29      1        3       5        7       9      11     13 

2000 

1800 
1700 
1G00 
1500 
1400 

TE 

MPE 

-lEATED   BED 
1ATURE  75   AN 

)  80° 

F- 

UNHEATE 
TEMP.    ROOM 

)  CH 
62-" 

0"F. 

HEATED   BED 
TEMP.    72-78" 

r. 

Fig.  142. — Showing  variations  in  weight  curve  of  an  infant  while  in  and  out  of 
a  heated  bed.  The  diet  was  unchanged  between  the  dates  September  19  and  October 
13. 


The  maintenance  of  desired  temperature  for  a  given  case  resolves 
itself  into  a  very  simple  problem  if  the  above  facts  relating  to  the 
recording  of  the  lid  thermometer  is  borne  in  mind,  in  that  the 
only  variable  factors  are  the  room  temperature  and  air  currents. 
The  former  in  most  hospital  rooms  will  average  from  65  to  75°  F. 
throughout  most  of  the  day,  and  the  ventilation  of  the  room  can 
easily  be  controlled.  In  most  cases  it  is  only  necessary  to  change 
the  rheostat  one  or  two  points  at  the  extremes  of  the  day,  as  at 
midnight  when  the  temperature  is  likely  to  fall,  and  in  the  morning 
when  the  hospital  temperature  is  again  more  uniform. 

We  require  recording  of  the  temperature  of  the  room  and  bed 
at  6  a.m.,  12  m.,  0  p.m.  and  12  p.m.  In  order  to  insure  safety  from 
extreme  heat  currents  and  extreme  fluctuations  in  room  tempera- 
ture the  point  of  the  rheostat  ward  temperatures  and  humidity 
should  also  be  recorded  at  these  times  (Fig.  88) . 

The  degree  of  temperature  to  be  maintained  within  the  bed 
must  of  necessity  vary  with  the  individual  infant  and  be  dependent 


CARE  OF  THE  BED  221 

in   part  at  least  upon   the  infant's  physical  development.     We 

rarely  find  it  necessary  to  maintain  a  temperature  above  (M)°  F. 
for  more  than  a  limited  number  of  hours  even  in  extreme  cases. 
In  small  infants  it  may  be  necessary  to  hold  the  temperature 
between  85  and  90°  F.  for  several  days.  Most  infants,  after  a 
few  days,  do  best  in  a  temperature  ranging  between  75°  and  80°  F., 
depending  upon  their  development.  An  average  of  76°  to  78°  F. 
will  answer  the  latter  needs  of  the  better  developed  infants.  It 
may  be  stated  that  moderate  fluctuations  of  3  to  5°  F.  in  the  tem- 
perature in  the  bed  during  the  course  of  the  day  have  little  detri- 
mental influence  on  the  infant's  progress.  Marked  fluctuations 
are  extremely  dangerous  (Fig.  142). 

Ventilation. —Ventilation  within  the  bed  is  maintained  automati- 
cally when  the  bed  is  heated.  This  is  due  to  the  fact  that  the  air  in 
the  center  of  the  bed  is  cooler  than  at  the  side  walls,  thereby  causing 
the  cooler  air  to  pass  into  the  bed  at  its  center,  then  to  flow  to  the 
floor,  along  the  floor,  to  the  side  walls  and  then  up  and  out  at  the 
sides.  The  direction  of  the  air  currents  within  the  bed  has  a 
double  advantage  in  that  the  infant  receives  the  renewed  fresh  air 
for  breathing  while  it  is  surrounded  by  the  warmed  air. 

Humidity.— Excessive  drying  of  the  air  is  prevented  by  the 
constant  circulation  through  the  bed  of  the  free  air  of  the  room  and 
by  evaporation  from  a  flat  basin,  containing  baked  porous  clay 
(as  used  in  water  filters),  over  which  water  is  poured  to  allow  of 
evaporation.  This  is  placed  on  the  floor  of  the  bed  immediately 
under  the  baby  basket.  Varying  with  the  degrees  of  temperature 
to  be  maintained  within  the  bed,  it  is  necessary  once  daily  to  supply 
from  S  to  16  ounces  of  water  to  replace  that  lost  through  evaporation. 

Dangers.— The  dangers  in  the  use  of  any  heated  bed  which  must 
at  all  times  be  avoided  to  insure  success  are: 

1.  Overheating  and  Refrigeration.— Reading  and  recording  of  the 
room  temperature,  the  rheostat  contact  and  the  bed  thermometer 
at  regular  intervals  throughout  the  day  will  furnish  the  necessary 
data  to  avoid  these  dangers. 

2.  Water  Hunger.— Fluids  must  be  supplied  to  an  amount  not 
less  than  one-sixth  to  one-eighth  of  the  infant's  body  weight  every 
twentv-four  hours  as  early  as  possible  following  birth.  (See  Feed- 
ing,  p.  181.) 

It  is,  therefore,  necessary  to  control  the  temperature,  ventilation 
and  humidity  of  the  bed,  and  to  keep  a  careful  supervision  of  the 
feeding,  more  particularly  the  fluid  intake.  Respiration  must  also 
be  carefully  watched  in  order  to  detect  cyanosis  and  asphyxia  suffi- 
ciently early  to  save  the  infant.  This  requires  that  these  infants 
be  observed  day  and  night. 

Xo  attempt  should  be  made  to  prevent  heat  loss  entirely  by 


222  INCUBATORS 

keeping  the  air  surrounding  the  infant  at  anywhere  near  its  body 
temperature.  Leaving  an  infant  in  such  an  environment  would 
soon  result  in  heat  stagnation  with  resulting  symptoms  of  heat 
stroke  which  is  early  evidenced  by  restlessness,  rapid  respiration 
and  dry  skin. 

The  bed  temperature  should  be  lowered  gradually  but  steadily 
until  it  reaches  72°  F.  The  best  method  of  judging  the  infant's 
external  temperature  requirements  is  by  taking  the  rectum  tempera- 
ture at  stated  intervals.  The  infant  should  be  graduated  from  the 
incubator  as  soon  as  its  general  condition  permits.  It  should  then 
be  kept  in  a  clean,  well- ventilated  room,  in  which  the  temperature 
can  be  stabilized  at  about  70°  F.  The  average  time  that  a  higher 
surrounding  temperature  will  be  indicated  will  vary  between  one 
and  eight  weeks  and  the  hospital  stay  from  two  to  ten  weeks. 
"Mothering,"  in  the  form  of  exercise,  and  massage  are  essential 
to  every  premature  once  its  physical  condition  permits  handling. 
The  same  is  true  of  needs  for  the  strictest  attention  to  its  personal 
hygiene. 

The  infant  should  be  discharged  to  its  home  as  soon  as"  possible 
for  several  reasons:  (1)  In  a  good  home  environment  it  will 
receive  more  individual  care  than  in  a  general  hospital;  (2)  the 
interest  of  the  mother  in  the  child  must  be  maintained;  (3)  placing 
the  infant  at  the  breast  is  the  best  way  of  maintaining  the  mother's 
milk  supply,  if  the  breasts  are  still  actively  secreting;  (4)  in  order 
to  prevent  "  hospitalism"  due  to  lack  of  "mothering"  and  a  tendency 
to  secondary  infections. 

The  bed  must  be  kept  scrupulously  clean. 

The  infant's  bedding  should  be  of  such  material  that  it  can 
be  destroyed  when  contaminated  by  vomit  and  excreta.  Feathers 
are  not  practical.  Untarred  jute  can  be  used  for  this  purpose. 
The  mattress  should  be  covered  by  a  heavy  pad  to  prevent  soiling. 

All  contact  with  infected  cases  and  attendants  must  be  avoided. 

All  visitors  are  best  excluded. 

The  conservation  of  heat  must  be  begun  immediately  after  birth. 

The  infant  must  be  properly  dressed;  its  head  as  well  as  its 
body  should  be  protected. 

The  body  temperature  of  the  infant  should  not  be  allowed  to 
go  lower  than  97  °  nor  above  98.6  °F.  Daily  fluctuations  greater  than 
1.5°  F.  are  dangerous. 

The  general  care  and  feeding  should  receive  the  most  careful 
attention. 

Above  all  else  all  care  administered  to  the  premature  should 
tend  to  individualization. 


HOME-MADE  HEATED  BEDS  22:') 

HOME-MADE  HEATED  BEDS. 

Emergency  Equipment.— As  many  of  the  cases  must  be  cared  for 
in  the  home  and  in  most  instances  without  time  or  facilities  to 
properly  equip  a  nursery,  every  physician  should  have  some  definite 
ideas  on  the  construction  of  a  bed  which  will  meet  exigencies  of 
the  individual  case.  We  have  already  spoken  of  the  general  care 
and  equipment  of  a  nursery  unit  in  the  home.  A  number  of  practi- 
cal emergency  beds  have  been  described,  the  specifications  of  a  few 
of  which  will  be  given  more  in  detail. 

A  small  wash  basket  well  padded  inside  and  outside  by  quilting, 
into  which  is  fitted  a  removable  platform  about  4  inches  above  the 
padded  floor  of  the  basket,  makes  a  fair  emergency  bed.  Beneath 
the  platform  in  the  floor  of  the  basket  hot-water  bottles  or  bags  are 
placed  which  must  be  refilled  from  time  to  time.  The  removal  of 
the  bags  for  refilling,  which  should  be  three  or  more  in  number  and 
which  are  to  be  filled  at  different  times,  is  facilitated  by  cutting  an 
opening  along  the  lower  outer  wall  of  the  basket  through  which  the 
water  bags  can  be  removed  at  will  without  disturbing  the  infant. 
A  box  can  be  built  for  this  purpose  to  even  better  advantage. 

Whether  a  box  or  basket  is  used  it  must  be  provided  with  some 
form  of  cover  for  three-quarters  of  its  upper  surface.  This  may 
be  accomplished  by  using  a  heavy  blanket  or  building  a  lid  to  fit. 

In  such  a  bed  the  infant  must  be  provided  with  proper  clothes 
as  previously  described  to  prevent  undue  heat  loss. 

This  bed  should  be  kept  in  a  well-ventilated  warm  room,  the 
temperature  of  which  should  range  between  68°  and  72°  F.  if 
possible. 

Brown26  describes  the  following  practical  home-made  heated  bed : 

Take  a  24-inch  wicker  clothes  basket  and  pad  the  bottom  with 
non-absorbent  cotton  to  a  depth  of  8  inches.  On  top  of  this  cotton 
fit  a  sheet  of  oilcloth,  sewing  the  edges  through  the  sides  of  the 
basket.  On  the  oilcloth  lay  a  double  layer  of  white  flannel  and  on 
the  flannel  a  napkin  of  absorbent  cotton.  Take  half  a  dozen  of 
12-ounce  citrate  of  magnesia  bottles  with  wire  and  rubber  corks 
and  cover  them  with  flannel.  These  bottles  are  filled  with  water 
at  110°  F.  and  hung  on  the  inside  walls  of  this  basket.  A  ther- 
mometer hung  inside  should  register  a  temperature  from  80°  to 
90°  F.  all  the  time.  At  night  an  oilcloth  is  spread  over  the  foot 
half  of  the  top  of  the  basket. 

Electric-heating  pads,  protected  by  copper  jackets,  have  been  in 
use  by  the  writer  over  a  period  of  several  years,  and  offer  a  valuable 
means  of  meeting  emergency  requirements.  They  are  also  valu- 
able for  use  in  the  home  where  the  temperature  cannot  be  well 
regulated  after  infants  leave  the  hospital  station.     Electric-heating 


224  INCUBATORS 

pads  have  lost  their  popularity  through  the  danger  of  fire  following 
short  circuit  due  to  broken  wires,  and  through  the  poor  quality 
of  the  thermostat  attachments  of  some  of  the  pads.  To  avoid  the 
danger  of  fire  from  short  circuits  in  electric-heating  pads,  a  copper 
receptacle  is  used,  16  inches  long,  13  inches  wide  and  1J  inches 
high,  into  which  a  12  x  15-inch  heating  pad  is  laid.  To  allow  of 
a  maximum  radiation  from  the  lid  or  upper  surface  of  the  same, 
the  floor  and  sides  are  lined  with  asbestos  sheeting,  while  the  lid 
is  not  lined.  The  cord  passes  through  a  small  rubber  insulator 
at  the  side  to  prevent  contact  with  the  metal  and  injury  to  the 
cord.  This  simple  device  can  be  used  temporarily  in  wards  and 
homes  where  better  facilities  for  the  care  of  this  class  of  infants  are 
lacking.  It  is  to  be  placed  in  the  bottom  of  a  basket  or  crib,  under 
the  mattress  or  pillow  (Fig.  143). 


Fig.  143. — Copper  receptacle  containing  pad. 

Litzenberg27  has  described  a  practical  bed  for  home  or  hospital 
use  for  which  the  specifications  are  as  follows.  A  box  24  inches 
long,  20  inches  high,  18  inches  wide.  Eight  inches  from  the  bottom 
is  a  false  bottom  dividing  the  box  into  two  chambers,  the  heating 
apparatus  being  in  the  smaller  lower  chamber  and  the  baby  in  the 
upper  one.  The  false  bottom  is  the  support  for  the  bed  of  the 
baby  and  does  not  cover  the  whole  bottom  of  the  box,  a  space  of 
4  inches  being  left  at  one  end  for  the  circulation  of  hot  air.  The 
top  of  the  box  may  be  fixed  on  hinges,  or  to  slide,  which  is  better. 
There  is  a  pane  of  glass  in  the  top  so  that  the  baby  may  be  watched, 
and  there  are  two  ventilating  holes  near  the  end  of  the  cover  oppo- 
site the  place  where  the  hot  air  enters.  An  ordinary  pillow  is 
laid  on  the  false  bottom  for  the  bed.  The  incubator  is  heated  by 
bottles  filled  with  very  hot  wTater  and  placed  in  the  lower  chamber 
through  a  small  door  in  the  side  of  the  chamber.     Fresh  air  enters 


HOME-MADE  HEATED  BEDS  225 

this  door,  passes  over  the  hot  bottles,  is  heated  and  ascends  by 
way  of  the  6-inch  space  at  the  end  of  the  box  to  the  baby's  chamber 
and  out  through  the  ventilating  holes  in  the  top,  giving  a  constant 
supply  of  warm  fresh  air.  A  thermometer  is  placed  in  the  incubator 
beside  the  baity,  or  better  beneath  the  first  fold  of  the  enveloping 
blanket. 

By  watching  this  thermometer  a  fairly  constant  temperature  can 
be  maintained  by  frequent  filling  of  the  bottles.  This  is  the  method 
usually  advised  for  heating.  He  has  further  devised  a  hot-air 
radiator  made  of  ordinary  3-inch  eaves-spouting.  A  temperature 
not  varying  2  to  3°  F.,  he  states,  is  easy  to  maintain.  The  heat 
from  the  chimney  of  an  ordinary  lamp  enters  the  spout  radiator 
through  an  elbow  1  inch  or  2  above  the  chimney.  This  elbow  curves 
upward  toward  the  box,  which  it  enters  by  way  of  a  hole  in  one 
end  of  the  chamber  where  the  spout  divides  into  two  parts  to  give 
more  radiating  surface.  These  two  branches  unite  at  the  other 
end  of  the  box,  and  the  warm  air  passes  out  through  a  hole  in  the 
end  without  entering  the  chamber  in  which  the  infant  is  placed. 
Thus,  the  products  of  combustion  in  the  lamp  do  not  enter  to 
injure  the  baby.  The  air  for  the  baby  enters  by  the  door  in  the 
side  of  the  box  described  before,  and  is  heated  by  the  hot  pipes 
and  ascends  to  the  baby.  Over  the  discharging  end  of  the  radiator 
is  a  cap  with  a  hole  1  inch  in  diameter.  This  discharge  hole  being 
very  small,  keeps  the  hot  air  from  rushing  through  without  radiating 
its  heat.  The  box  can  easily  be  made  collapsible  so  that  the  whole 
thing  can  be  slipped  under  the  seat  of  a  buggy  and  be  set  up  complete 
in  less  than  five  minutes. 

Specifications.— Board  1  inch  thick,  10  inches  wide  and  21  feet 
long.  Cut  six  pieces  2  feet  long  and  one  piece  18  inches  long. 
On  four  of  the  2-foot  pieces  nail  a  small  cleat,  the  full  width  of  the 
board,  1  inch  from  each  end.  Eight  inches  from  the  edge  of  two 
of  the  2-foot  pieces  nail  a  cleat  parallel  to  the  long  way  of  the 
piece  and  on  the  same  side  of  the  piece  as  the  small  cleat.  In  the 
center  of  the  18-inch  piece  cut  a  hole  3.25  inches  in  diameter.  Now 
set  the  pieces  with  the  long  cleat  on  edge.  The  cleats  will  face 
each  other  and  be  8  inches  from  the  floor.  Place  one  of  the  18-inch 
pieces  with  the  hole  in  it  against  the  end  cleats  of  the  two  side 
pieces  and  fasten  them  there  by  means  of  two  hooks  screwed  into 
the  short  edge  of  the  side  pieces,  the  hook  fastening  in  a  staple  or 
ring  in  the  18-inch  piece.  Fasten  the  other  end  in  the  same  manner 
and  then  place  the  radiator  in  the  two  holes  at  the  end.  Now 
lay  two  of  the  18-inch  pieces  on  the  long  cleat,  and  you  have  the 
false  bottom  or  bed  support.  The  other  2-foot  pieces  with  the 
cleats  are  now  put  together  with  the  two  remaining  18-inch  pieces 
with  hooks  arranged  as  described,  and  when  put  together  they  are 
15 


226  INCUBATORS 

placed  on  top  of  the  first  set  and  securely  fastened,  thus  making  a 
box  18  x  20  x  24  inches.  There  now  remain  two  of  the  2-foot 
pieces  which  are  fastened  together  with  several  cleats  to  make  a 
top.  A  hole  about  8  x  10  inches  is  cut  near  one  end  of  the  top 
for  a  window  for  observing  the  child,  and  still  nearer  the  end  are 
cut  two  ventilating  holes  about  2  inches  in  diameter. 

ROOM  INCUBATORS. 

The  room  incubator  or  so-called  giant  incubator  claiming  to  have 
all  the  advantages  of  little  incubators  without  their  inconveniences, 
was  constructed  in  Lyon,  France,  for  the  first  time  in  1886  by 
H.  Colrat.  It  consisted  of  a  room  12  feet  long  and  8  feet  wide.  Its 
two  main  features  were  an  attempt  to  hold  a  constant  temperature, 
and  a  system  of  aeration  permitting  of  renewing  the  air.  It  was, 
no  doubt,  a  good  innovation  at  that  time. 

In  1900  Arnaud,  of  Turin,  introduced  the  hot-air  room,  and  it 
found  followers  in  other  cities. 

The  incubator  chambers  built  by  Escherich  and  Pfaundler  in 
Graz  and  Vienna,  Brauer  in  Marburg  and  Langstein  in  the  Kaiserin 
Auguste-Victoria  House  in  Berlin  are  all  of  the  same  type  with 
added  improvements.  They  are  completely  enclosed  cells  of  glass 
and  metal  construction,  having  sufficient  room  for  two  or  more 
infant  beds,  obtaining  the  air  from  outside  and  are  provided  with 
automatic  regulation  of  gas  heating,  ventilation  and  humidification. 
Between  the  cells  and  the  nursery  room  there  is  a  small  space 
providing  against  cooling  of  the  infant  when  the  door  of  the  incu- 
bator is  opened.  It  is  possible  to  change  the  clothing  of  the  infants, 
to  bathe  them  and  to  feed  them  in  the  room  (Fig.  144). 

Several  clinics  in  the  United  States  have  built  such  rooms,  among 
them  Washington  University,  of  St.  Louis,  and  Michael  Reese 
Hospital,  Chicago.1 

1  Specification  of  Warm  Room,  Washington  University,  St.  Louis. — The  fresh  air 
from  outside  is  driven  in  by  an  electric  fan.  It  then  passes  over  a  system  of  steam 
coils  enclosed  in  a  closed  steel  cabinet,  and  is  moistened  by  steam  escaping  through 
a  small  valve  within  the  cabinet.  Thermostat  contact  is  used.  The  air  makes  a 
complete  circuit  of  the  heated  chamber  and  passes  into  a  closed  shaft  and  enters 
the  room  through  small  registers  located  in  the  shaft.  The  used  air  leaves  the 
room  through  the  out-going  shafts  of  the  ventilating  system.  The  room  itself  is 
insulated  and  the  windows  double.  A  thermometer  and  hygrometer  are  placed 
near  a  window  and  are  visible  from  the  corridor.  A  nurse  records  the  room  tempera- 
ture and  humidity  on  a  chart  every  hour.  To  hold  the  room  temperature  at  approx- 
imately 80°  F.  and  humidity  at  55°  F.,  regular  inspection  is  necessary  because  of 
the  unsatisfactory  working  of  the  thermostat. 

Specifications  of  Warm  Room,  University  of  California,  San  Francisco. — The  room 
is  9  by  11  feet,  with  an  11-foot  ceiling.  It  accommodates  five  infants,  the  cribs 
being  separated  by  glass  partitions  4  feet  high,  extending  2\  feet  out  from  the  side 
wall.     Entrance  is  through  double  doors  so  placed  that  the  outer  one  is  closed  before 


ROOM  I XCU BATONS 


227 


I 

GROUND   PLAN. 


Fig.  144. — Incubator  room.     Escherieh-Pfaundler  sj  stem. 


the  inner  one  is  opened.  A  larjie  window  at  the  opposite  end  admits  ample  light, 
and  a  closet  is  provided  for  gowns  and  supplies.  Furniture  consists  of  a  dressing 
table,  chair  and  scales.  The  ventilating  system  delivers  200  cubic  feet  of  air  per 
minute,  thus  affording  a  complete  change  of  air  every  five  minutes.  A  thermostat 
and  hygrometer  maintain  constant  temperature  and  humidity  of  the  entering  air. 
The  room  is  kept  at  80°  F.  The  infants  arrive  from  the  delivery  room  and  are 
placed  beside  the  radiator,  additional  heat  being  furnished  by  hot-water  bottles  if 


228 


INCUBATORS 


Some  of  the  greater  difficulties  to  be  overcome  are  the  automatic 
heat  regulation,  the  cost  of  equipment  and  maintenance  when  only 
a  small  number  of  children  are  to  be  cared  for,  the  distress  caused 
the  attendants  when  they  are  required  to  remain  for  a  considerable 
period  in  the  heated  room,  and  most  important  the  difficulty 
encountered  in  individualizing  the  care  of  premature  infants  of 
different  ages  and  stages  of  development. 

The  disadvantages  of  the  larger  incubator  room  have  led  in  many 
clinics  to  their  being  discarded,  among  others  that  at  the  Michael 
Reese  Hospital.  More  practical  is  a  room  provided  with  special 
facilities  for  heating  and  ventilation  which  can  be  used  in  conjunction 
with  individual  heated  beds. 

In  its  primitive  form  an  incubator  room  may  be  provided  in  a 
private  home  by  heating  the  room  to  75°  to  80°  F.,  at  the  same 
time  making  provision  for  moistening  the  air  sufficiently  by  hang- 
ing wet  clothes  near  the  stoves  or  radiators.  It  is,  of  course, 
impossible  to  maintain  a  constant  temperature  and  ventilation  by 
such  crude  means,  so  that  in  conjunction  with  a  more  moderately 


Fig.  145. — Heated  room  used  as  station  for  the  care  of  premature  infants  (Uni- 
versity of  California,  San  Francisco,  California).  Showing  individual  cubicles, 
built  on  a  shelf  running  across  the  room. 


necessary.  It  is  seldom  necessary  to  keep  them  here  longer  than  twenty-four  hours, 
after  which  they  maintain  a  fairly  steady  body  temperature  with  the  room  at  80°  F. 
and  no  additional  heat  in  the  crib. 

Michael  Reese  Hospital  Incubator  Room. — The  specifications  of  this  room  are  as 
follows.  It  is  16j  feet  long  by  10  feet  wide,  with  a  plate-glass  partition  cutting  off 
a  vestibule  6  by  10,  in  which  the  nurse  may  stay  out  of  the  greater  heat  of  the  incu- 
bator room  proper.  The  incubator  room  itself  is  a  cube  10  feet  each  way,  lined 
with  cork,  felt  and  asbestos,  besides  the  other  normal  coverings.  There  is  a  double 
window  with  separate  double  transom,  and  exhaust  fan  and  an  intake  fan. 


TRANSPORT  AT  I  OX  INCUBATORS 


229 


heated  room,  70°  to  75°  F.,  some  type  of  individual  bed   for  the 
further  protection  of  the  infant  should  be  used. 

A  modification  of  the  incubator  room  and  doing  away  with  some 
of  its  disadvantages  has  been  installed  in  the  Sloan  Maternity 
Hospital,  in  New  York,  described  by  Dr.  E.  15.  Cragin.  It  is 
possessed  of  many  valuable  features,  such  as  filtered  air,  the  absorp- 
tion of  air  by  an  electric  fan  and  the  serial  electric  light  heating. 
The  disadvantages  are  to  be  found  in  the  inability  to  individualize 
the  infant  care  and  the  necessity  for  constant  supervision  (Fig.146). 


m 


^n^) 


®d 


®       © f 


Fig.   146. — The  Sloan  Hospital  incubator. 

Selection  of  Method  for  Supplying  Artificial  Heat.— This  must  of 
necessity  depend  upon  the  facilities  at  hand.  Every  community 
should  be  supplied  with  the  proper  equipment  for  handling  these 
infants.  Such  a  station  should  be  a  part  of  every  maternity  depart- 
ment. In  institutions  more  especially  designed  for  the  care  of 
infants,  a  more  elaborate  station  should  be  supplied  and  wet  nurses 
should  be  available. 


TRANSPORTATION  INCUBATORS. 

Probably  the  most  important  epoch  in  the  life  of  the  premature 
infant  is  that  period  between  birth  and  the  institution  of  some 
proper  method  for  the  prevention  of  refrigeration.  It  is  the  experi- 
ence of  all  institutions  receiving  such  infants  that  many  of  them 


230 


INCUBATORS 


are  lost  through  carelessness  in  protecting  them  during  the  first 
hours  after  birth.  The  figures  of  Ylppo  are  illuminating  on  this 
point. 

TEMPERATURE    ON   ADMISSION   AND   MORTALITY   OF   PREMATURE 

INFANTS. 

Temperature  37  to  35  Temperature  28  J- 

degrees.     Died  within  degrees.     Died  within 

the  first  month.  the  first  month. 

Per  cent.  Per  cent. 
Group  I< 

600  to  1000  gm 66.6  100.0 

Group  II: 

1001  to  1500  gm 37.5  85.7 

Group  III: 

1501  to  2000  gm 21.05  60.0 

Group  IV: 

2001  to  2500  gm.       .....       5.88  20.0 

By  looking  at  the  above  table  we  may  easily  come  to  a  one-sided 
conclusion  that  the  mortality  of  the  premature  infants  is  in  the 
first  place  influenced  by  the  more  or  less  severe  initial  cooling 


Fig.  147. — Obstetrical  bag  with  false  bottom  designed  by  the  author  as  a  trans- 
portation incubator. 

occurring  after  birth,  and  that  therefore  the  mortality  of  the 
premature  infants  may  be  markedly  reduced  by  painstaking  care 
in  preservation  of  heat. 

A  simple  trans portatiori  incubator  can  be  made  by  the  employment 
of  an  ordinary  obstetrical  bag  with  a  false  bottom.     Hot-water 


TRANSPORTATION  INCUBATORS 


231 


bags  or  bottles  can  be  carried  in  the  lower  compartment,  and  the 
infant  in  the  bag  proper.  It  is  only  necessary  to  make  a  sufficient 
number  of  f-inch  holes  beneath  the  handle  for  ventilation.  These 
should  be  reinforced  by  a  metal  rim  so  that  they  cannot  collapse 
and  cut  off  the  supply  of  air.  The  fresh-air  supply  can  be  con- 
trolled by  a  metal  slide  covering  these  holes  or  by  using  corks. 
Eight  larger  holes  should  be  made  in  the  floor  of  the  satchel,  so 
that  the  heat  can  pass  from  the  lower  compartment  into  the  upper 
compartment.  These  are  best  made  close  to  the  edge  at  the  ends, 
so  that  thev  will  be  less  likely  to  be  covered  by  the  bedding  (Fig. 
147). 


Fig.  148.  —  DeLee  transportation  incubator. 


The  De  Lee  incubator  ambulance  is  a  minature  incubator  with  a 
circulating  hot-water  system  heated  from  the  outside  by  an  alcohol 
lamp.  It  is  well  ventilated  and  lighted  by  electricity.  It  is  21 
inches  long,  11  inches  wide  and  11  inches  high  (Fig.  14S). 

Welde25  has  described  a  transportation  incubator  which  is  rather 
simple  in  construction  (Figs.  149  and  150). 

Heat  is  supplied  by  a  thermophor  or  hot  water  bottles  placed  in 
lower  compartment. 


Fig.  149. — Inner  case,  o,  air  compartment;  A,  inner  metal  box;  b,  sliding  door; 
d,  removable  upper  wall  of  the  double  floor;  c,  lower  air  holes;  e,  upper  air  holes; 
a,  double  floor. 


C        n 
Tig.  150. — Outer  case.     B,  outer  wood  case;     K,  lid  of  wooden  case;    L,  glass 
window;    h,  felt  lining;    m,  carrying  strap;    e,  upper  air  holes;    n,  handles;    c,  lower 
air  holes;    g,  windows  in  inner  case;    /,  removable  lid  of  inner  case. 


TRANSPORTATION  INCUBATORS  233 


Bibliography. 

1.  Denuce:     Jour,  de  med.  de  Bordeaux,  December,  1857. 

2.  Clementovsky:     Oesterr.  Jahrb.  f.  Padiatrik,  1873,  3,  .'50. 

3.  Pasquad:      La  couveuse  artificielle  chez  les  nouveau-nes,  These  de  Paris,  1899. 

4.  Crede:     Arch.  f.  Gyniik.,  1884,  24,  128. 

5.  Winckel:     Centralbl.  f.  Gynak.,  1882,  Nr.  1  bis  3. 

6.  Tarnier:     Sie  wurde  1881  in  der  Maternite  aufgestellt  und  wohl  zuerst  in 
einer  Arbeit  von  Auvard  (Arch,  de  Tocologie,  October,  1883)  beschrieben. 

7.  Auvard:     Arch,  de  Tocologie,  1883,  p.  577. 

8.  Berthod:     La  couveuse  et  le  gavage  a  la  maternite  de  Paris,  These  de  Paris, 
1887. 

9.  Hearson:     Zit.  nach  Czerny-Keller,  1,  673. 

10.  Eustache:     Jour,  d  sc.  med.  de  Lille,  1885. 

11.  Diffre:     Montpelier  med.,  1896. 

12.  Lion:     Zit.  nach  Czerny-Keller,  1,  673. 

13.  Pajot:     Zit.  nach  Budin,   Manuel  pratique  d'allaitement,  Paris,   1905. 

14.  Budin:     Le  Nourrisson,  Paris,  1900. 

15.  Hutinel  and  Delestre:     Revue  mens,  des  mal.  de  l'enfance,  1899,  17,  529. 

16.  Finkelstein:     Lehrbuch  der  Sauglingskrankheiten,  Berbn,  1905,  II  Teil,  s.  32. 

17.  Rommel:     Miinchen.  med.  Wchnschr.,  1900,  Nr.  11. 

18.  Polanos:     Miinchen.  med.  Wchnschr.,  1903,  Nr.  35,  s.  1498. 

19.  Escherich  and  Pfaundler,  L.:     Mitt.  d.  Vereins  d.  Arzte  in  Steiermark,  1900, 
Nr.  3. 

20.  Colerat:     Societe  des  sciences  medicales  de  Lyon,  1896. 

21.  Arnaud:     LaSala  incubatrice;    Contribute  alio  studio  della  fisiopatologia  dei 
neonati  prematuri,  Torino,  1900. 

22.  Cragin,  E.  B.:     Jour.  Am.  Med.  Assn.,  No.  11,  63,  947. 

23.  Ylppo:     Ztschr.  f.  Kinderheilkunde. 

24.  DeLee:     Obstetrics  for  Nurses,  W.  B.  Saunders  Co.,  Philadelphia,  1919. 

25.  Welde:     Jahrb.  f.  Kinderheilkunde,  1912,  75,  551. 

26.  Brown,  Alan:     Arch.  Pediat.,  No.  8,  34,  609. 

27.  Litzenberg:     J.  Minnesota  Med.  Assn.,  Minneapolis,  28,  87,  91,  1908. 


PART  III. 
GENERAL  DISEASES. 


CHAPTER  X. 
DISEASES  OF  THE  RESPIRATORY  TRACT. 

ASPHYXIA  NEONATORUM. 

Asphyxia  is  a  condition  produced  by  any  interference  with 
oxygenation  of  the  blood.  It  may  be  present  at  birth  or  it  may 
occur  subsequent  to  that  event.  Asphyxia  in  the  new  born  is 
characterized  by  an  absence  or  feebleness  of  respiration  which  is 
accompanied  by  cardiac  action,  showing  that  life  is  present. 
Asphyxia  occurring  after  birth  is  most  frequently  due  to  pre- 
maturity or  to  congenital  weakness. 

During  intra-uterine  life  the  wants  of  the  fetus  are  supplied 
from  the  maternal  blood  stream  through  the  placenta,  oxygen 
being  present  in  sufficient  quantities  so  that  respiration  is  unneces- 
sary. Normally  this  state  of  apnea  terminates  at  birth  and  respi- 
ration is  established,  in  all  probability,  as  a  result  of  the  decreasing 
supply  of  oxygen  derived  from  the  placental  circulation,  and  of 
the  increasing  amount  of  carbon  dioxide  which  is  accumulating 
in  the  fetal  blood,  and  upon  which  the  stimulation  of  the  medullary 
center  depends,  the  fetus  passing  from  a  condition  of  apnea  to 
one  of  dyspnea.  At  the  same  time  the  heart  action  is  slowed  and 
the  blood-pressure  raised,  both  the  result  of  the  carbon-dioxide 
stimulation.  Since  the  respiratory  center  is  only  with  difficulty 
affected  in  the  premature,  it  is  sluggish  in  responding  to  the  increase 
of  carbon  dioxide,  and  if  this  increase  is  slow  in  appearance  respira- 
tion may  not  be  attempted  at  all.  Cutaneous  stimulation  from 
extraneous  influences  in  the  outer  world  also  plays  a  part  in  the 
establishment  of  primary  respiration. 

Etiology.-  Asphyxia  of  the  premature  newborn  may  be  due  to 
any  one  of  the  many  causes  which  interfere  with  the  oxygen  supply 
of  the  fetus  either  before  or  during  labor.  These  causes  may  be 
listed  as  follows: 


236  DISEASES  OF  THE  RESPIRATORY  TRACT 

1.  Abnormally  strong  and  prolonged  labor  pains.  Such  lengthy 
and  oft-repeated  uterine  contractions  may  interfere  with  the 
exchange  of  gases  in  the  placenta  or  with  the  oxygen-laden  umbilical 
blood  stream. 

2.  Unequal  pressure  exerted  by  the  uterus  after  the  membranes 
have  ruptured,  if  applied  to  the  placenta  or  the  cord,  may  prevent 
oxygen  reaching  the  fetus. 

3.  Compression  or  tearing  of  the  placenta. 

4.  Twisting  or  tearing  of  the  cord  or  its  compression  while  in 
the  uterine  cavity  or  when  prolapsed. 

5.  Premature  separation  of  the  placenta,  either  complete  or 
partial. 

6.  Slow  labor  the  result  of  weak  pains  or  contracted  pelvis. 

7.  Premature  respirations  resulting  from  attempts  at  version  or 
from  the  application  of  forceps.  In  this  instance  the  aspiration 
of  amniotic  fluid  or  vaginal  mucus  usually  forms  the  obstruction 
to  respiration. 

8.  Maternal  anemia  or  asphyxia  from  renal,  cardiac  or  pulmonary 
affections,  diseases  of  the  blood,  eclampsia  or  other  forms  of  toxemia 
such  as  are  produced  by  morphine,  chloroform,  etc. 

In  the  extra-uterine  variety  of  asphyxia  the  infant  attempts  respi- 
ration after  birth  but  is  unsuccessful.  The  reason  for  this  failure 
may  be  due  to  the  presence  of  mucus,  blood  or  liquor  amnii  in  the 
respiratory  passages;  to  the  presence  of  anomalies  of  the  heart 
or  lungs;  to  injuries  of  the  skull;  to  the  pressure  from  cerebral 
hemorrhage;  or  to  inherent  constitutional  weakness  or  weakness 
of  the  respiratory  muscles.  In  the  premature  infant  the  respiratory 
center  is  but  insufficiently  developed,  the  respiratory  muscles  are 
weak  and  the  lungs  are  in  a  state  bordering  more  or  less  closely 
upon  fetal  atelectasis.  All  of  these  factors  favor  the  development 
of  asphyxia,  and  the  younger  the  fetal  age  of  the  infant  at  the 
time  of  birth,  the  more  pronounced  are  these  conditions,  though 
it  must  be  remembered  that  not  all  premature  infants  are  debilitated 
(see  Atelectasis). 

Cerebral  pressure  from  injuries  of  the  skull  or  from  intracranial 
hemorrhage  causes  anemia  of  the  medulla  and  consequently  pre- 
vents stimulation  of  the  respiratory  center  with  resulting  lack  of 
respiratory  activity,  or  with  stimulation  of  the  vagus  with  excessive 
slowing  of  the  pulse,  which  interferes  with  the  exchange  of  gases 
through  the  placenta  or  the  lungs. 

Our  present  belief  is  that  the  asphyxia  occurring  immediately 
after  birth  is  due  to  oxygen  deficiency  and  to  paralysis  of  the 
respiratory  center  by  overloading  the  blood  with  carbon  dioxide. 
The  presence  of  atelectasis  and  pulmonary  congestion  and  edema 
favors  the  development  of  this  state,  which  is  so  frequent  in  pre- 


ASPHXIA  NEONATORUM  237 

matures  and  leads  to  general  acidosis.  Ylppo  demonstrated  in 
living  premature  infants  alkalinity  of  the  blood  lower  than  thai 
ever  found  in  the  blood  of  adults.  Conditions  are  thus  favorable 
for  excessive  acidification  of  the  organism,  not  only  by  carbon 
dioxide  but  also  by  the  other  acid  products  of  metabolism.  Because 
of  the  abnormal  reaction  of  the  blood  the  irritability  of  the  respira- 
tory center  is  early  reduced,  leading  to  asphyxia]  attacks.  In 
addition,  it  must  be  borne  in  mind  that  the  frequency  of  cerebral 
and  spinal  hemorrhages  in  the  smaller  prematures  will  explain 
asphyxial  attacks  occurring  in  the  first  two  or  three  months  of  life. 
Finally,  traumatic  lesions  of  the  respiratory  center  may,  in  them- 
selves, lead  to  disturbances  in  respiration  and  to  interference  with 
oxygen  intake. 

Morbid  Anatomy.— Examination  of  the  body  of  a  premature 
new-born  infant,  dead  of  asphyxia,  shows  besides  the  evidences 
of  prematurity,  marked  congestion  of  the  internal  organs.  The 
right  heart,  sinuses  of  the  dura  and  the  great  vessels  are  filled  with 
blood.  The  brain  and  the  organs  in  the  thoracic  and  abdominal 
cavities  are  congested  and  edematous.  Small  hemorrhages  are 
found  in  the  pleura,  pericardium,  peritoneum,  liver,  kidneys, 
adrenals  and  retina.  Occasionally  effusions  are  seen  in  the  serous 
cavities.  In  the  lung  areas  of  aerated  tissue  are  seen  along  with 
areas  of  atelectasis,  and  the  trachea  and  bronchi  may  be  found 
filled  with  mucus  or  amniotic  fluid.  Edema  of  the  extremities 
and  scrotum  may  be  present.  Extravasations  of  blood  are  found 
in  the  skin  and  mucous  membranes  as  well  as  in  the  internal 
organs. 

Symptoms.— The  strong  premature  infant  at  birth  behaves  much 
as  does  the  full-term  healthy  child;  it  breathes  deeply,  utters  a 
more  or  less  vigorous  cry,  and  the  skin  which  at  first  is  of  a  purplish 
hue  rapidly  becomes  pink.  If  asphyxia  exists  two  sets  of  symptoms 
may  present  themselves,  depending  upon  the  variety  of  asphyxia, 
asphyxia  livida  or  asphyxia  pallida. 

In  asphyxia  livida  or  asphyxia  of  the  first  degree  the  skin  has 
a  reddish-blue  or  bluish  tinge,  the  face  is  swollen,  the  eyes  protrude 
somewhat  and  the  conjunctivae  are  injected.  The  extremities 
remain  passive  though  the  muscles  retain  their  tonicity  or  are 
even  hypertonic;  the  heart  beats  strongly  and  the  apex-beat  is 
often  apparent  to  the  eye;  the  vessels  of  the  cord  are  filled  with 
blood  and  pulsate;  the  respiratory  efforts  may  be  absent  or  shallow 
and  infrequent.  These  infants  can  be  roused  and  made  to  cry, 
respirations  being  established  after  suitable  measures  of  resuscita- 
tion have  been  used. 

In  asphyxia  pallida,  or  asphyxia  of  the  second  degree,  the  vaso- 
motor center  is  overstimulated  by  the  excess  of  carbon  dioxide 


238  DISEASES  OF  THE  RESPIRATORY  TRACT 

in  the  blood  and  this  overstimulation  causes  contraction  of  the 
peripheral  vessels  with  venous  engorgement  of  the  deeper  vessels, 
thus  further  overloading  the  heart.  The  face  is  of  a  waxy  pallor, 
the  visible  mucous  surfaces  are  cyanosed,  the  muscle  tone  is  lost 
and  the  extremities  hang  lax.  The  reflex  irritability  is  lost;  there 
is  no  attempt  at  respiration  or  at  the  most  very  feeble  efforts;  the 
pulsations  of  the  heart  are  weak  and  either  fast  or  slow,  and  the 
pulsations  in  the  cord  are  absent  or  only  weakly  perceptible.  The 
distinguishing  feature  that  separates  this  condition  from  asphyxia 
livida  is  the  lack  of  muscle  tone  in  the  pallid  form,  these  infants 
having  a  corpse-like  appearance  and  only  the  presence  of  the  heart 
action  and  the  few  feeble  respiratory  gasps  show  that  the  infant  is 
not  dead. 

Further  Course.  — If  an  asphyxiated  infant  is  revived  it  frequently 
remains  somewhat  apathetic,  cries  very  little  and  does  not  nurse 
well,  requiring  artificial  aid  in  obtaining  nourishment.  In  the 
stronger  infants,  however,  this  condition  tends  to  clear  up,  so  that 
in  a  few  days  the  cry  is  vigorous,  the  movements  active  and  the 
ability  to  nurse  is  good.  In  the  weakling,  whether  premature  or 
full-term,  such  improvement  is  much  slower.  The  poorly  devel- 
oped respiratory  mechanism  results  in  superficial  and  irregular 
breathing  and  the  existence  of  areas  of  atelectasis  tends  to  delay 
development  of  the  lung.  These  weak  infants  may  have  breathed 
spontaneously  at  birth  though  not  enough  to  have  dilated  the 
alveoli  of  the  lungs  to  a  sufficient  degree  and  as  a  result  repeated 
attacks  of  cyanosis  occur.  These  attacks  of  cyanosis  are  accom- 
panied by  a  condition  of  apnea  which  lasts  a  moment  or  longer, 
during  which  the  infant  ceases  to  breathe  entirely.  These  attacks 
appear  without  warning  and  may  be  very  frequent  in  the  weaker 
infants  during  the  first  two  weeks  of  life,  and  are  evidently  the 
result  of  lowered  irritability  of  the  respiratory  center.  The  outlook 
for  the  infant  in  these  spells  is  not  good,  despite  the  fact  that  treat- 
ment is  undertaken,  because  they  are  an  indication  of  inherent 
weakness  in  the  individual.  In  those  cases  which  are  to  recover, 
these  attacks  of  cyanosis  become  less  and  less  severe  and  less 
frequent. 

The  after-life  of  these  infants  may  be  affected  to  some  extent 
as  the  persistence  of  a  degree  of  atelectasis  renders  them  less  resist- 
ant to  infection. 

Sequelae.— Cerebral  symptoms  that  develop  later  are  not  at  all 
infrequent  in  children  asphyxiated  at  birth  and  probably  depend 
upon  cerebral  sclerosis  secondary  to  minute  intracranial  hemor- 
rhages. Developmental  cerebral  anomalies  or  injuries  may, 
however,  be  primary  causes  of  asphyxia  and  may  later  be  evidenced 
by  motor  and  psychic  disturbances. 


ASPHYXIA  NEONATORUM  239 

Diagnosis.— Asphyxia  must  be  differentiated  from  hemorrhage  of 
meningeal  or  cerebral  origin  occurring  during  prolonged  or  abnormal 
labor  or  after  the  application  of  forceps.  The  symptoms  of  a 
slight  hemorrhage  resemble  those  of  asphyxia,  the  breathing  being 
very  superficial  with  frequent  lapses  into  stupor.  Convulsions 
occasionally  occur  and  the  pulse  may  be  slow  or  fast.  Continued 
slow  pulse  with  the  occurrence  of  coma  and  convulsions  speak 
strongly  for  a  cerebral  hemorrhage,  especially  after  a  prolonged 
labor  or  the  application  of  forceps.  The  differentiation  is  extremely 
difficult  during  the  first  days  of  life  in  premature  and  weak  infants 
and  death  frequently  results  before  the  etiological  factor  is  ascer- 
tained. Delmas1  recommends  lumbar  puncture  as  a  diagnostic 
and  therapeutic  measure. 

Prognosis.— The  outlook  for  strong  prematures  suffering  from 
asphyxia  livida  is  good,  the  majority  recovering  under  proper 
treatment.  In  the  weaklings  it  is  always  grave.  In  asphyxia 
pallida  the  prognosis  is  bad,  the  infant  invariably  succumbing  if 
left  to  itself.  If  the  heart  action  improves  while  attempts  at 
resuscitation  are  being  made  it  is  a  favorable  sign.  Endeavors  to 
revive  the  infant  should  be  kept  up  until  the  heart  ceases  to  beat. 
At  all  times  undue  violence  must  be  avoided,  all  attempts  at  resus- 
citation being  applied  gently  and  at  regular  intervals  to  avoid 
visceral  injury.  If  cerebral  hemorrhage  is  combined  with  asphyxia 
the  outlook  is  very  poor. 

The  cause  of  death  in  asphyxia  may  be  a  recurrence  of  the 
asphyxial  attacks,  lowered  irritability  of  the  respiratory  center, 
atelectasis  of  the  lung  or  blocking  of  the  air  passages  by  inspired 
foreign  matter  or  cardiac  failure. 

Treatment.— The  treatment  of  asphyxia  is  concerned  with  clearing 
the  respiratory  passages  and  supplying  oxygen  to  the  tissues.  In 
the  milder  cases  the  finger  is  gently  introduced  into  the  pharynx, 
or  the  throat  stroked  downward,  while  the  child  is  held  in  an 
inverted  position,  sufficient  to  clear  out  the  obstruction  to  respira- 
tion. In  the  cases  of  asphyxia  livida  there  is  usually  mucus  in 
the  trachea  or  bronchi,  and  this  can  frequently  be  removed  suffi- 
ciently to  allow  of  respiratory  activity  by  inverting  the  infant  and 
introducing  a  catheter  as  far  as  the  upper  opening  of  the  larynx. 
Only  in  the  larger  infants  is  it  possible  to  pass  the  catheter  into 
the  larynx.  Suction  is  made  with  the  lips  and  the  mucus  is  drawn 
into  the  catheter.  Occasionally  it  is  necessary  to  repeat  this 
maneuver  several  times.  The  dangers  of  a  syphilitic  infection  are 
to  be  remembered. 

Once  the  passages  are  cleared  of  mucus  the  reflex  stimulation 

1  Le  Progres  medical,  1912,  40,  88-89. 


240  DISEASES  OF  THE  RESPIRATORY  TRACT 

of  respiration  by  external  irritation  is  attempted.  In  the  milder 
cases  the  back  and  buttocks  of  the  suspended  child  are  gently 
slapped,  cool  (90°  F.)  water  is  sprinkled  over  the  body,  or  the 
latter  is  rubbed  with  a  warm  cloth.  In  the  severer  cases  the  child 
is  immersed  in  hot  water  at  a  temperature  of  40.5°  C.  (105°  F.) 
for  a  few  minutes  and  then  in  a  cool  bath  for  an  instant.  The 
warm  bath  relieves  the  vasoconstrictor  spasm  and  the  overloaded 
heart,  the  blood  being  brought  to  the  surface.  Weak  mustard 
baths,  warm  enemata  and  careful  compression  of  the  chest  are  all 
advocated. 

In  the  severest  cases  cutaneous  stimulation  is  not  sufficient 
and  it  becomes  necessary  to  resort  to  artificial  respiration. 

Insufflation  has  dangers,  especially  for  the  premature  infant 
whose  pulmonary  tissue  is  very  delicate.  If  the  lung  is  torn  emphy- 
sema follows  and  only  a  slight  tear  is  necessary  because  of  the 
very  poorly  developed  state  of  the  elastic  tissue  in  the  lung  of 
the  premature.  On  this  account  it  is  best  to  use  some  method 
by  which  the  amount  of  air  to  be  forced  into  the  lungs  may  be 
measured.  The  capacity  of  the  lungs  being  about  30  cc,  the  use 
of  a  thin  rubber  bulb  of  a  capacity  smaller  than  this  would  obviate 
the  risk  of  tearing  the  lung  tissue.  The  difficulty  of  entering  the 
trachea  of  these  small  premature  infants  must  be  kept  in  mind. 

The  choice  of  the  method  to  be  used  in  inducing  artificial  respi- 
ration depends  upon  the  severity  of  the  asphyxia.  There  is  no 
use  wasting  time  in  spanking  the  back  or  making  traction  on  the 
tongue  in  the  severer  cases.  In  the  lighter  forms  the  simpler 
measures  usually  suffice,  but  in  asphyxia  pallida  more  energetic 
measures  must  be  practised.  First  the  air  passages  are  cleared  and 
then  Prochownik's  method  is  used  for  thirty  seconds.  If  this  is 
unsuccessful  the  tracheal  catheter  is  inserted  with  great  care  and 
the  lungs  dilated  with  air. 

The  treatment  of  secondary  asphyxia!  attacks  consists  in  the 
use  of  warm  baths,  oxygen  insufflations  and  artificial  respiration. 
The  oxygen  tank  should  be  kept  at  the  side  of  the  infant's  bed  and 
either  continuous  or  intermittent  showers  of  oxygen  given  in  the 
attempt  to  ward  off  cyanotic  attacks  (see  Cyanosis). 

The  intracutaneous  injection  of  oxygen  with  an  aspirator  has 
been  recommended  in  the  treatment  of  asphyxia  by  Delmas.1 
He  advises  injecting  from  30  to  60  cc  beneath  the  skin,  from  which 
region  it  is  readily  absorbed  with  beneficial  effect.  In  the  opinion 
of  the  author  such  injections,  because  of  the  considerable  trauma 
and  shock,  might  result  disastrously  in  the  treatment  of  premature 
infants. 

Reanimation  of  asphyxiated  infants  by  the  insufflation  method 

1  La  medecine  infantile,  1912,  16,[21U. 


CYANOSIS  241 

of  Meltzer  and  Auer  is,  according  to  Planclni,  quite  practicable 
and  efficient.  In  this  method  a  current  of  air,  directed  as  far  as 
the  tracheal  bifurcation  through  a  small  catheter,  ventilates  the 
lungs  sufficiently  to  oxygenate  the  blood  even  if  no  respiratory 
movements  occur.  The  necessary  apparatus  consists  of  a  rubber 
bulb,  a  small  mercury  manometer  and  a  Xo.  12  (French  sejile 
rubber  catheter.  A  rod  of  soft  copper  is  placed  in  the  lumen  of 
the  catheter  to  give  it  the  proper  shape  for  introduction  and  the 
catheter  itself  is  marked  with  transverse  lines  at  8,  10  and  12  cm. 
from  the  tip,  indicating  the  distance  from  the  mouth  to  the 
bifurcation  of  the  trachea  in  a  2000-,  3000-  and  4000-gm.  child, 
respectively. 

The  method  of  the  procedure  is  as  follows:  With  the  little 
finger  or  a  small  gauze  sponge  in  the  hold  of  a  forceps  any  mucus 
in  the  infant's  throat  is  removed  and  the  child  is  then  wrapped  in 
a  blanket  and  placed  with  the  neck  slightly  overextended.  The 
index  finger  of  the  left  hand  is  introduced  as  far  as  the  upper  border 
of  the  larynx,  finding  the  soft  opening  of  the  glottis.  The  catheter 
is  introduced  by  the  right  hand  between  the  tongue  and  the  palmar 
surface  of  the  left  index  finger  into  the  laryngeal  opening.  When 
it  has  reached  the  proper  distance  the  copper  rod  is  removed,  the 
insufflation  apparatus  attached  and  air  injected  with  the  bulb 
the  pressure  not  exceeding  10  or  15  mm.  of  mercury. 

The  insufflation  may  be  continued  as  long  as  needed.  Soon 
the  child  appears  less  relaxed  and  the  heart  tones  become  stronger 
and  more  regular  and  respiratory  movements  begin. 

In  infants  weighing  under  2000  gm.  the  larynx  and  trachea  are 
passed  only  with  great  difficulty  because  of  their  small  diameter, 
and  the  dangers  of  secondary  infection  due  to  trauma  of  the  tissue 
is  great. 

The  use  of  the  pulmotor  or  lung  motor,  several  modification-  of 
which  are  on  the  market,  is  not  to  be  recommended  in  treating 
the  asphyxia  of  premature  infants,  because  of  the  danger  of  rupture 
of  the  delicate  pulmonary  tissue. 

CYANOSIS. 

Of  all  functions  of  the  premature  infant,  that  of  respiration  is 
usually  the  least  developed  at  birth,  evidencing  to  a  marked  degree 
the  general  lack  of  development  of  the  central  nervous  system. 
Failure  on  the  part  of  the  respiratory  apparatus  to  respond  in  a 
sufficient  manner  to  the  needs  of  the  infant  is  the  most  frequent 
cause  of  symptoms  of  the  gravest  nature  in  these  weaklings  and 
indeed  not  seldom  of  death  itself. 

The  underlying  factors  in  the  production  of  cyanosis  may  be 
16 


242  DISEASES  OF  THE  RESPIRATORY  TRACT 

divided   into   inherent   and   extraneous.     The  inherent  causes   of 
cyanosis  are: 

1.  Lack  of  development  of  the  central  nervous  system,  especially 
of  the  respiratory  center. 

2.  Weakness  of  the  general  musculature  and  softness  of  the 
ribs. 

3.  Persistence  of  fetal  atelectasis  which  tends  to  delay  develop- 
ment of  the  lungs. 

4.  Congenital  malformations  of  the  heart  or  great  vessels  or 
myocardial  asthenia. 

5.  Malformations  of  the  respiratory  tract  or  of  the  diaphragm. 

6.  Diseases  or  compression  of  the  air  passages. 

7.  Injuries  of  the  skull  or  cerebral  hemorrhage. 

8.  Obstruction  to  nasal  breathing. 

9.  A  birth  weight  below  1200  gm.  These  infants  almost  invari- 
ably suffer  from  attacks  of  cyanosis. 

10.  Cooling  of  the  body  is  given  as  a  cause  by  Budin,  but  many 
infants  have  a  temperature  of  95°  F.  or  even  93°  F.  without  the 
occurrence  of  cyanosis. 

11.  Elevation  of  the  body  temperature  to  more  than  102°  F. 
is  given  by  Zahorsky  as  a  cause. 

In  the  premature  infant  the  causes  among  the  above  which  are 
chiefly  operative  in  the  production  of  the  characteristic  attacks 
of  cyanosis  are  the  weak  respiratory  muscles,  the  softness  of  the 
ribs,  the  underdevelopment  of  the  centers  of  respiration  and  the 
presence  of  fetal  atelectasis. 

Involvement  of  the  heart  is  ordinarily  of  secondary  occurrence, 
the  diminished  amount  of  oxygen  in  the  blood  resulting  in  a  slowing 
and  weakening  of  the  heart's  action.  The  atelectasis  which  is  so 
frequently  present,  tends  to  hinder  the  closure  of  the  foramen 
ovale  and  the  ductus  Botalli  and  these  defects  in  turn  predispose 
to  cyanosis. 

The  extraneous  causes  include: 

1.  The  aspiration  of  food  or  vomitus  into  the  larynx  or  trachea. 
The  lack  of  development  of  the  pharyngeal  and  laryngeal  reflexes 
is  responsible  for  the  food  reaching  the  air  passages  and  the  lack 
of  reflex  cough  prevents  its  being  ejected.  Pneumonia  not  infre- 
quently follows  the  aspiration  of  such  foreign  particles. 

2.  Distention  of  the  stomach  from  overfeeding.  This  is  one  of 
the  most  common  causes  of  cyanosis  and  death  in  premature 
infants.     This  leads  to  interference  with  the  action  of  the  diaphragm. 

3.  Meteorism,  due  to  gastric  and  intestinal  stasis. 

4.  Attempts  at  drinking  are  often  followed  by  cyanosis,  either 
the  direct  result  of  the  mechanical  prevention  of  respiration  or 
secondarily  through  the  lessened  oxygen  content  of  the  blood, 


CYANOSIS  243 

resulting  in  a  hick  of  stimulation  of  the  respiratory  centers  (von 
Reuss). 

5.  Undernourishment  is  strongly  advanced  by  Budin  as  a  causa- 
tive of  cyanosis,  and  he  has  shown  that  with  increased   feeding 

these  attacks  stop. 

(i.  An  insufficient  supply  of  water. 

7.  The  occurrence  of  a  local  or  general  infection. 

Symptoms.— Oftentimes,  without  apparent  cause,  attack-  of 
cyanosis  appear  with  frequency  during  the  first  few  weeks  of  the 
life  of  the  premature  or  weakly  infant.  Usually  without  warning 
the  respirations,  which  have  previously  been  superficial  and  irregu- 
lar, become  still  weaker  and  then  cease  entirely  for  a  minute  or 
longer,  somewhat  resembling  the  Cheyne-Stokes'  type  of  breathing. 
Accompanying  the  apnea  is  a  deep  cyanosis  which  gradually  dis- 
appears as  breathing  is  resumed.  Not  infrequently,  if  immediate 
steps  to  restore  the  respiratory  activity  to  something  like  the  nor- 
mal are  not  taken,  the  infant  dies;  in  other  cases  breathing  is 
spontaneously  resumed  and  the  attack  passes  off,  leaving  the 
infant  more  or  less  prostrated.  Care  must  be  taken  in  pronouncing 
it  dead  before  examination  for  heart  sounds.  In  a  few  hours  or 
days  cyanosis  recurs,  the  attacks  gradually  increasing  in  length 
and  severity  despite  treatment,  until  death  occurs;  or  they  become 
less  frequent  until  they  cease  entirely. 

Occasionally  the  attacks  are  preceded  or  accompanied  by  con- 
vulsions.    Generalized  edema  sometimes  develops. 

Diagnosis.— From  congenital  cyanosis  due  to  other  causes, 
or  acute  affections  of  the  respiratory  tract  with  cyanosis,  these 
attacks  are  differentiated  by  the  history  or  other  evidence  of 
premature  birth,  and  the  frequently  accompanying  cyanotic 
edema,  the  respiratory  weakness,  absence  of  the  normal  vesicular 
breathing,  particularly  over  the  bases  and  the  tendency  to  a 
subnormal  temperature. 

Prognosis.— The  prognosis  of  cyanosis  in  the  premature  infant 
varies  directly  with  the  severity  of  the  attacks  which  in  turn  are 
more  or  less  directly  dependent  upon  the  fetal  age  and  physiological 
development,  the  ability  of  the  infant  to  maintain  its  body  tempera- 
ture, the  quality  of  the  food  and  the  ease  with  which  the  infant 
digests  it. 

In  no  other  condition  to  which  these  infants  are  subject  is  the 
previous  training  and  experience  of  the  attending  nurse  in  the 
care  and  handling  of  this  class  of  cases,  of  such  vast  importance. 

Treatment.— A  premature  infant  must  be  carefully  watched  for 
signs  of  cyanosis,  otherwise  it  may  be  found  dead  in  bed.  Should 
an  attack  occur  while  the  child  is  being  fed,  the  proceeding  must 
be  stopped  and  efforts  made  to  restore  respiration.     The  first  thing 


244  DISEASES  OF  THE  RESPIRATORY  TRACT 

to  do  is  to  ascertain  if  there  is  any  obstruction  in  the  upper  respira- 
tory passages.  Should  inspired  food  or  vomitus  be  present,  an 
effort  must  be  made  to  dislodge  these  particles.  Inserting  the  little 
ringer  into  the  pharynx  while  the  child  is  in  an  inverted  position, 
often  serves  to  clear  out  the  respiratory  tube,  and  then  slight 
cutaneous  stimulation  by  pinching,  friction  or  gentle  slapping  is 
often  enough  to  reinitiate  breathing. 

Again,  exhaustion  of  the  infant  may  be  solely  responsible  for 
the  cyanosis.  In  these  cases  artificial  respiration  should  be  tried, 
the  chest  being  rhythmically  pressed  upon,  or  one  of  the  other 
methods  of  artificial  respiration  may  be  tried.  Simple  compression 
of  the  chest  may  be  tried  without  removal  from  the  incubator  or 
bed,  though  removal  will  be  found  more  serviceable  generally. 

The  use  of  oxygen  is  of  value  in  quickly  reducing  the  degree 
of  asphyxia  after  breathing  is  once  established,  although  it  will 
not  of  itself  restore  that  function.  A  tank  should  be  kept  by 
the  infant's  bed  and  any  sign  of  approaching  asphyxia  should  be 
the  indication  for  the  generous  shower  of  oxygen.  The  continued 
use  of  the  gas  when  properly  applied  is  advocated  as  a  valuable 
measure  in  the  checking  of  attacks.  About  80  to  100  bubbles  of 
oxygen  gas  from  a  partially  protected  mask  should  escape  in  close 
proximity  to  the  infant's  mouth. 

Aromatic  spirits  of  ammonia  in  one-half  to  two  drop  doses, 
diluted,  is  of  value,  and  nitroglycerin,  one  drop  of  a  1 :  1000  solution 
may  be  placed  on  the  tongue.  The  use  of  camphor,  caffein,  atropin 
or  other  respiratory  stimulants  hypodermically  does  not  offer 
much  practical  help. 

Sprinkling  the  baby  with  cool  water  will  occasionally  stimulate 
respiration  and  as  this  means  is  always  at  hand  it  should  be  kept 
in  mind. 

Infants  suffering  from  repeated  attacks  of  cyanosis  should  be 
immersed  in  a  hot  bath  at  a  temperature  of  102°  to  105°  F.,  and 
subjected  to  gentle  friction,  more  especially  along  the  spinal  column. 
The  infant  may  be  kept  in  the  bath  for  from  a  few  seconds  to  several 
minutes,  when  it  should  again  be  placed  in  its  warmed  bed,  avoid- 
ing all  chilling.  The  efficiency  of  the  bath  may  be  increased  by 
the  addition  of  a  teaspoonful  of  mustard  to  the  gallon  of  water. 
Care  should  be  taken  to  prevent  aspiration  of  the  bath  water,  or 
its  entrance  into  the  eyes,  and  the  danger  of  infection  of  the  umbili- 
cal cord,  although  not  great  must  be  borne  in  mind.  The  bath 
may  be  repeated  as  indicated. 

In  our  own  experience  the  warm  mustard  bath  has  proven  one  of 
the  most  satisfactory  means  of  overcoming  prolonged  attacks.  It 
is  quite  evident  that  the  facilities  for  preparing  the  bath  must  be 
prearranged  and  great  care  taken  to  keep  it  at  an  even  temperature 


CYANOSIS  •  245 

throughout  the  immersion.  To  facilitate  handling  and  to  prevent 
undue  manipulation  during  the  cyanotic  attacks  the  infant  should 
be  wrapped  in  a  blanket. 

It  cannot  be  too  strongly  emphasized  that  the  manipulation*  used 
to  relieve  the  cyanosis  should  be  the  minimum  necessary  to  accomplish 
the  result  as  cyanotic  infants  react  poorly  to  trauma.  After  an  attack 
is  over  the  infant  should  be  placed  in  a  warm  bed  or  bath  in  order 
to  overcome  the  tendency  to  a  reduction  of  temperature  by  the 
previous  manipulations.  Afterward  it  is  also  necessary  to  supervise 
carefully  the  feeding  in  order  that  two  things  may  be  accomplished: 
(1)  That  the  occurrence  of  further  attacks  of  cyanosis  due  to 
mechanical  obstruction  by  food  may  be  prevented;  and  (2)  that  the 
nutrition  of  these  weaklings  may  be  immediately  bettered  and  thus 
the  cyanosis  indirectly  controlled. 

The  prevention  of  cyanosis  may  be  aided  in  several  ways.  The 
too  rapid  taking  of  food  or  distention  of  the  stomach  by  over- 
feeding must  be  avoided  (see  Feedings).  Underfeeding  in  cases 
where  too  frequent  feeding  is  undesirable  can  be  avoided  by  catheter 
feeding  at  longer  intervals,  although  the  maximum  food  quantities 
must  be  carefully  ascertained  by  starting  with  minimum  feedings, 
carefully  increased  according  to  the  infant's  tolerance.  Catheter 
feeding  is  not  well  borne  by  all  infants  and  may  occasionally  in 
itself  induce  cyanosis.  The  strength  of  the  infant  should  be  built 
up  as  rapidly  as  possible,  and  the  temperature  of  the  body  should 
be  maintained  by  the  use  of  the  heated  bed  inasmuch  as  a  lowering 
of  the  body  temperature  not  only  favors  the  development  of  cyanotic 
attacks,  but  makes  them  more  severe  when  they  do  occur.  The 
use  of  oxygen  may  be  of  value. 

Insufficient  supply  of  fluids  should  be  avoided  by  the  administra- 
tion of  water  where  the  fluid  intake  is  less  than  one-sixth  of  the 
body  weight  during  the  twenty-four  hours. 

Meteorism  may  be  relieved  by  small  quantities  of  low  saline 
enemata,  part  of  which  may  be  left  in  the  rectum  to  good  advantage 
where  the  fluid  intake  per  mouth  is  insufficient  to  meet  the  body 
requirements. 

Gastric  lavage  must  occasionally  be  resorted  to  as  a  means  of 
last  resort  in  overdistention  of  the  stomach  with  paresis  of  its 
walls  and  should  be  performed  with  the  infant's  head  at  a  lower 
level  than  the  body  to  prevent  aspiration  of  stomach  contents,  as 
passage  of  the  tube  very  frequently  results  in  vomiting.  This 
procedure  is  always  associated  with  great  danger  during  a  cyanotic 
attack.  Occasionally  the  gas  can  be  relieved  by  simple  passage 
of  the  catheter  into  the  stomach  with  slight  pressure  from  without 
over  the  epigastric  region. 


240  DISEASES  OF  THE  RESPIRATORY  TRACT 

DISEASES  OF  THE  NASAL  PASSAGES. 

The  anatomy  of  the  nasal  passages  of  the  new-born  infant  is 
such  that  comparatively  small  degrees  of  swelling  or  accumulations 
of  mucus  are  sufficient  to  lead  to  obstruction  of  nasal  respiration, 
thereby  interfering  with  the  act  of  nursing.  When  during  sleep 
the  tongue  falls  backward,  thus  occluding  the  passage  between 
the  pillars,  attacks  of  cyanosis  and  dyspnea  may  result. 

A  nasal  discharge  present  at  birth  or  developing  within  the 
first  two  or  three  weeks  of  life  should  lead  to  a  search  for  evidence 
of  congenital  lues.  When  the  syphilitic  infection  is  sufficiently 
virulent  to  cause  premature  labor  the  external  manifestations 
usually  appear  early. 

Other  sources  of  infection  of  the  nasal  mucosa  can  be  found  in 
the  passage  of  the  child  through  the  maternal  birth  canal,  from 
the  bath  water  or  by  direct  transmission  from  an  individual  suffering 
from  a  similar  infection.  The  organisms  which  may  be  concerned 
include  the  various  pyogenic  bacteria,  the  pneumococcus,  colon 
bacillus,  influenza  bacillus  and,  less  frequently,  the  gonococcus. 
The  diphtheria  bacillus  is  frequently  seen  as  a  cause  in  institutional 
infants. 

Obstruction  of  the  posterior  nares  is  occasionally  seen  in  the 
new-born  premature,  the  opening  being  closed  by  either  a  mem- 
branous or  a  bony  partition.  When  bilateral  it  favors  respiratory 
obstruction  and  may  be  the  direct  cause  of  attacks  of  asphyxia 
and  cyanosis.  Xasal  infections  may  threaten  the  infant  by  exten- 
sion to  the  lower  respiratory  passages,  while  generalized  septic 
processes  may  have  their  origin  in  a  nasal  infection. 

Treatment. —The  prophylaxis  of  nasal  infections  requires  that  if 
the  mother  is  suffering  from  any  infection  of  the  respiratory  tract 
every  effort  should  be  made  to  prevent  infection  of  the  offspring. 
Coughing  or  direct  breathing  into  the  infant's  face  should  be 
avoided  and  care  taken  that  infectious  material  is  not  carried 
from  one  to  the  other  on  the  hands,  or  by  means  of  infected  articles. 
The  same  precautions  must  be  taken  in  case  an  attendant  is  the 
one  infected.  A  vaginal  discharge  from  the  mother  at  the  time  of 
delivery  requires  that  the  infant's  nose  should  be  cleaned  thoroughly 
but  carefully  with  a  cotton  pledget  after  birth.  Lowered  resistance 
due  to  chilling  of  the  infant  is  an  important  etiological  factor  and 
must  be  avoided. 

It  may  become  necessary  to  remove  crust  formation  with  instilla- 
tions of  normal  salt  or  weak  alkaline  solutions.  This  must  be 
carefully  performed  to  avoid  forcing  the  infection  into  the  Eusta- 
chian tube  and  air  passages,  small  quantities  only  being  used. 
Pledgets  of  cotton  saturated  with  1:1000  solution  of  adrenalin  chlo- 


CONGENITAL  STRIDORS  247 

ride  if  placed  within  the  nostril  will  temporarily  relieve  the  nasal 
swelling.  As  curative  agents  some  of  the  organic  silver  salts  in 
weak  solutions  may  be  mentioned.  The  use  of  an  ointment  of 
the  yellow  oxide  of  mercury  (ung.  hydrarg.  ox.  flaw)  of  ()..">  or  1 
per  cent  strength  will  be  found  of  value.  A  portion  the  size  of  a 
small  pea  should  be  introduced  into  the  anterior  nares  and  the 
nostril  then  gently  massaged  in  order  to  force  the  ointment  as  far 
into  the  nose  as  possible.  In  cases  of  syphilitic  or  diphtheritic 
infections  specific  treatment  must  be  instituted. 

The  breast-feeding  of  these  infants  with  rhinitis  offer-  some 
difficulty  because  of  the  interference  with  respiration  which  accom- 
panies obstructions  of  the  nose.  Nursing  at  the  breast  is  likely 
to  be  a  difficult  matter  under  the  most  ideal  circumstances  when 
the  infant  is  as  weak  as  many  prematures  are,  and  if  added  to  this 
is  an  inability  to  breathe  while  sucking  and  swallowing.  The 
difficulties  are  so  great  at  times,  even  in  infants  approaching  matur- 
ity, that  it  becomes  necessary  to  feed  expressed  milk  per  catheter. 
This  method  of  food  administration  must  be  instituted  before 
the  infant  shows  the  results  of  inanition. 

CONGENITAL  STRIDORS. 

Congenital  Laryngeal  Stridor.— In  the  premature  infant  the 
presence  of  a  stridor  may  go  unnoticed  for  several  days  because 
of  the  weak  inspiratory  effort,  in  contradistinction  to  the  full- 
term  infant  in  which  it  is  usually  interpreted  in  the  first  days 
of  life.  It  must,  therefore,  be  expected  that  the  croaking  or  crow- 
ing sound  will  be  much  more  feeble  than  is  usually  heard  in  these 
cases.  The  stridor  usually  disappears  when  the  infant  is  deeply 
asleep,  which  in  the  premature  is  the  greater  part  of  its  day.  Unless 
there  is  a  considerable  stenosis,  the  infant  shows  no  distress  and 
cyanosis  is  absent.  During  intense  crying  and  in  the  presence  of 
cyanotic  attacks,  signs  of  obstruction  may  become  evident.  It  is 
often  difficult  to  make  an  exact  diagnosis  in  these  cases  because  of 
the  dangers  of  direct  transillumination  of  the  larynx  in  these  small 
infants  and  the  diagnosis  is  often  dependent  on  the  ability  of  the 
clinician  to  exclude  other  causes  of  inspiratory  dyspnea.  Two 
cases  examined  by  the  author  at  autopsy  have  in  both  instances 
shown  similar  findings,  in  that  there  was  a  marked  narrowing 
of  the  lumen  of  the  larynx  with  thickening  of  the  aryepiglottic 
folds  and  deformity  of  the  epiglottis.  Nervous  disturbances  due 
to  arrested  development  in  the  cortical  centers  with  resulting 
disturbed  coordination  of  the  act  of  respiration  may  occasionally 
be  a  causative  factor.  Arrest  of  development  affecting  the  center 
for  the  recurrent  nerve  may  also  be  another  factor. 


248  DISEASES  OF  THE  RESPIRATORY  TRACT 

Treatment.— There  is  usually  a  spontaneous  functional  correction. 
The  prophylactic  care  should  consist  in  the  prevention  of  respira- 
tory infections. 

Stridor  Thymicus. — The  frequency  of  true  thymic  enlargement 
with  direct  tracheal  pressure  has  undoubtedly  been  exaggerated 
by  incomplete  diagnosis.  The  most  frequent  sign  proving  stenosis 
of  the  upper  air  passages  is  the  presence  of  suprasternal  retraction. 
In  the  premature  the  tendency  of  the  entire  chest  wall  to  collapse 
with  each  inspiration  may  be  mistaken  for  this  sign  and  easily  lead 
to  an  error  in  diagnosis.  The  author  has  seen  two  such  cases 
which  were  verified  by  palpation  of  a  soft  tumor  mass  in  the  fossa 


Fig.  151. — Specimen  of  thymus  gland  weighing  40  gm.,  and  resulting  in  thymic 

death. 

jugularis  during  expiration  as  well  as  by  percussion  with  flatness  to 
the  right  and  left  of  the  manubrium  and  substantiated  by  roentgen- 
ray  findings.  In  both  cases  the  stridor  developed  shortly  after 
birth  and  disappeared  spontaneously  with  diminution  in  size  of 
the  thymus  gland,  both  infants  making  an  uneventful  recovery. 
The  author  has  also  seen  a  case  of  congenital  thymus  stridor  in  a 
luetic  infant  which  died  on  the  sixth  day.  At  autopsy  the  thymus 
gland  weighed  40  gm.  and  was  the  seat  of  numerous  miliary 
abscesses. 

Prognosis.— The  prognosis  varies  with  the  cause  of  enlargement. 
The  benign   forms  which  disappear  spontaneously  undoubtedly 


SUFFOCATION  FROM  EXTERNAL  CAUSES  249 

belong  to  the  vascular  type.  While  the  number  of  sudden  deaths 
due  to  causes  associated  either  directly  or  indirectly  with  the 
thymus  gland  are  less  frequent  than  one  would  be  led  to  believe 
from  a  review  of  the  literature,  they  do  occur  and  must  be  given 
proper  consideration.  These  deaths  may  be  due  to  mechanical 
compression  of  the  trachea  by  an  enlarged  gland  either  due  to  a 
true  hypertrophy  or  hemorrhage  within  the  gland,  or  death  may 
be  caused  by  hypersecretion  of  the  gland.  Syphilitic  changes  in 
the  thymus  with  miliary  abscess  formation  has  already  been  de- 
scribed as  a  cause  of  death  under  Thymic  Stridor. 

Treatment.— An  expectant  attitude  should  be  adopted  in  the 
absence  of  marked  signs  of  stenosis.  In  the  presence  of  congenital 
lues,  specific  treatment  should  be  instituted.  The  only  other 
form  of  treatment  which  offers  any  degree  of  encouragement  is 
that  of  roentgen-ray  exposure  in  the  hope  of  creating  rapid  involu- 
tion, with  the  development  of  moderate  fibrosis.  Friedlander1 
describes  prompt  results,  stating  that  dyspnea  is  lessened  even 
after  the  first  treatment. 

It  is  self-evident  that  the  exposure  of  premature  infants  to  the 
roentgen  ray,  unless  carefully  guarded,  may  be  disastrous  not 
alone  in  the  too  rapid  atrophy  of  the  thymus  gland  which  is  so 
necessary  to  the  growing  organism,  but  also  to  the  thyroid  and 
other  parenchymatous  organs  as  well  as  the  danger  of  skin  irritation. 

In  our  wards  at  Michael  Reese  Hospital,  Dr.  R.  A.  Arens  makes 
use  of  the  following  treatment: 
8  inch  spark  gap. 

3  mm.  aluminum  filter. 

10  inch  S.T.I).  (Skin  Target  Distance). 
5  M.A.  (milliamperes). 

4  minutes  exposure. 

The  treatment  is  guided  entirely  by  the  clinical  course.  Fre- 
quently one  or  two  treatments  are  sufficient. 

Stridor  from  Other  Causes.— These  are  most  commonly  due  to 
congenital  enlargement  of  the  thyroid  gland  which  is  usually  of 
the  vascular  type  and  disappears  spontaneously  without  treatment. 
Congenital  tracheal  stenosis,  deformities  of  the  mouth,  congenital 
tumors  of  the  mouth  and  acute  inflammatory  conditions  of  the 
upper  respiratory  passages  may  be  further  causes. 

SUFFOCATION  FROM  EXTERNAL  CAUSES. 

Death  from  suffocation  due  to  external  causes  such  as  faulty 
position  (infant  on  face),  obstruction  of  breathing  by  clothing  or 

1  Am.  Jour.  Dis.  Child.,  6,  38. 


250  DISEASES  OF  THE  RESPIRATORY  TRACT 

overlying  on  the  part  of  the  parent  have  been  responsible  for  the 
loss  of  many  premature  and  weakly  infants.  These  have  often 
been  described  as  instances  of  thymic  death.  Death  from  these 
causes  is  far  less  common  in  full-term,  robust  new-born  infants,  as 
the  latter  possess  the  ability  to  change  the  position  of  the  head 
when  threatened  with  suffocation. 

AFFECTIONS  OF  THE  BRONCHI  AND  OF  THE  LUNGS. 

1.  Congenital  Anomalies. 

Fetal  Bronchiectasis.— Fetal  bronchiectasis  is  a  rare  condition  of 
the  new  born  which  affects  the  whole  or  only  part  of  one  lung. 
Universal  bronchiectasis  is  the  result  of  hydremic  degeneration  of 
an  entire  bronchus,  the  lung  structure  being  replaced  by  cystic 
formations  which  contain  a  serous  fluid  in  which  are  found  ciliated 
epithelium  and  nuclei. 

The  teleangiectatic  bronchiectasis  is  characterized  by  the  forma- 
tion either  of  individual  cysts  or  less  often  of  multilocular  sacs, 
the  walls  of  the  cysts  being  lined  with  several  layers  of  cuboidal 
epithelium. 

A  third  variety  known  as  atelectatic  bronchiectasis  is  due  usually 
to  lack  of  development  of  certain  portions  of  the  lung  which  later 
become  cirrhotic  from  pressure  from  a  bronchus.     (Birnbaum.1) 

Hypoplasia  and  Hyperplasia.— These  malformations  are  due 
either  to  lack  of  sufficient  development  or  to  excessive  development. 
In  hypoplasia  a  small  airless  structure  is  found  in  place  of  one  lung. 
Since  the  healthy  lung  in  such  cases  usually  grows  into  the  empty 
half  of  the  thoracic  cavity,  deformity  results,  the  thoracic  wall  not 
developing  well  over  the  healthy  lung.  The  same  is  true  of  primary 
hypertrophy,  which  consists  either  in  abnormal  size  or  in  forma- 
tion of  supernumerary  lobes  (Birnbaum.) 

Diagnosis.— On  account  of  the  equalizing  growth  of  the  healthy 
lung  the  diagnosis  is  possible  only  in  the  presence  of  deadening  of 
the  sounds  over  one-half  of  the  thorax.  This  is  much  more  import- 
ant in  the  new  born  than  in  older  children,  since  in  the  latter  the 
above-mentioned  physical  finding  is  much  more  significant  of  an 
infiltration  or  exudation  (von  Reuss.2)  Roentgen-ray  studies  are 
of  assistance  in  localizing  the  lesion  although  they  may  not  deter- 
mine the  type  of  lesion. 

Bronchiectasis  in  the  new  born  is  not  accompanied  by  any  dis- 
tinctive symptoms.  In  the  premature  their  existence  increases 
the  respiratory  handicap  under  which  these  infants  labor,  and  if 

1  Congenital  Diseases  of  the  Fetus,  Springer,  Berlin,  1909. 

2  Diseases  of  the  New  Born,  Springer,  Berlin,  1914. 


Affect ioxs  of  the  hroxchi  and  Of  the  WNGS    251 

they  are  extensive,  death  with  symptoms  of  asphyxia  usually  occur- 
soon  after  birth.  The  occurrence  of  inflammatory  complications 
makes  the  outlook  still  graver. 

Atelectasis.— Atelectasis  is  also  spoken  of  as  acquired  asphyxia 
though  it  may  be  congenital  as  it  is  a  persistence  of  the  Fetal  state 
in  all  or  in  part  of  the  lung.  In  the  congenital  variety  the  lung 
is  not  entirely  expanded  at  birth,  while  in  the  acquired  form  collapse 
of  the  previously  expanded  lung  occurs.  The  congenital  variety 
is  seen  chiefly  in  the  premature  and  debilitated,  either  due  to  a 
developmental  anomaly  or  insufficient  strength  on  the  part  of  the 
respiratory  muscles  to  inflate  the  lungs.  The  acquired  form  is 
most  frequently  due  to  obstruction  of  the  bronchi  or  alveoli  by 
intrathoracic  exudates,  diaphragmatic  hernias  and  deformities  of 
the  spinal  column. 

Atelectasis  is  to  a  degree  physiological  during  the  first  few  days 
after  birth,  gradually  disappearing  with  increasing  strength. 
When  associated  with  asphyxia  at  birth,  it  is  often  overcome 
entirely  by  the  means  used  to  revive  the  infant. 

In  the  weak  the  methods  used  are  not  enough  to  cause  complete 
expansion  of  the  lung  and  collapsed  areas  persist,  the  soft  and  yield- 
ing thoracic  wall  and  poorly  developed  respiratory  muscles  of  the 
premature  both  favoring  the  non-expansion. 

The  cyanosis  which  is  so  frequently  seen  in  those  suffering  from 
atelectasis  may  be  directly  due  to  the  aspiration  of  food  into  the 
larynx,  the  absence  of  the  pharyngeal  and  laryngeal  reflexes  favor- 
ing this.  Mechanical  interference  with  respiration  during  the  act 
of  drinking  may  also  result  in  cyanotic  attacks;  interference  with 
the  action  of  the  diaphragm  through  overdistention  of  the  stomach 
(Birk1)  and  according  to  Budin2  underfeeding,  may  both  be  respons- 
ible for  cyanosis  in  the  premature.     (See  Cyanosis.) 

Pulmonary  atelectasis  also  occurs  after  cerebral  hemorrhage,  due 
to  injury  to  the  respiratory  center,  and  is  characterized  by  small 
respiratory  excursions  and  slight  exchange  of  gases.  In  the  pre- 
mature the  irritability  of  the  respiratory  center  is  low  a  prion, 
while  in  those  suffering  from  natal  asphyxia  it  is  lowered  by  the 
asphyxia. 

Pathology.— The  anterior  portions  of  the  lungs  are  most  fre- 
quently the  portions  expanded,  the  paravertebral  parts  being 
atelectatic.  Peiser3  showed  that  in  organs  hardened  in  situ  the 
central  portion  near  the  hilus  was  also  atelectatic,  while  the  api<  es 
and  borders  were  usually  expanded,  the  expanded  portions  often 
being    emphysematous    (Holt4).     When    death    occurred    early    a 

1  Leitfaden  dcr  Sauglingskrankheiten,  Marcus  and  Webers,  Balm.  I'M  I. 

2  The  Nursling,  Caxton  Pub.  Co.,  London,  1907. 

3  Jahrb.  f.  Kinderh.,  1908,  67,  589. 

4  Diseases  of  Infancy  and  Childhood,  D.  Appleton  &  <  V>.,  NCw  York,  1913. 


252 


DISEASES  OF  THE  RESPIRATORY  TRACT 


large  portion  of  the  lung  was  usually  not  inflated.  The  left  lung 
is  usually  more  atelectatic  than  the  right.  The  involved  parts  are 
rich  in  blood  and  thus  form  sites  of  predilection  for  inflammatory 
processes. 

Hemorrhages  and  edema  frequently  complicate  this  condition, 
which  is  made  worse  by  the  deficient  heart  action.  These  hemor- 
rhages are  chiefly  in  the  region  of  the  hilus.  In  vessel  injuries  of 
lesser  degree  there  is  no  bleeding,  only  edematous  extravasation. 


Fig.  152. — Congenital  atelectasia.     Four-fifths  normal  size  and  magnification  of  6 

diameters. 


The  atelectatic  lung  is  of  brownish-red  color,  does  not  crepitate, 
is  very  vascular  and  shows  the  lobular  outline  on  the  surface. 
Usually  both  lungs  are  affected  to  the  same  degree.  The  heart 
frequently  shows  the  presence  of  a  patent  foramen  ovale  or  other 
congenital  lesion,  the  liver  and  spleen  are  often  congested  and  the 
latter  may  be  enlarged  (Fig.  152). 

Symptoms.— Very  frequently  the  subjects  of  atelectasis  give  a 
history  of  asphyxia  at  birth;  in  others  there  may  have  been 
nothing  to  attract  attention  to  the  lungs.     Some  are  noticeably 


AFFECTIONS  OF  THE  BRONCHI  AND  OF  THE  LUNGS     253 

quiet,  cry  weakly,  sleep  much  and  their  voices  are  feeble.  The 
temperature  is  usually  below  the  normal;  occasionally  there  is 
some  edema  of  the  extremities  or  slight  puffiness  of  tlie  face, 
while  the  breathing  is  shallow  and  often  irregular.  The  gain  in 
weight  is  slight  or  absent,  and  the  children  remain  small  and  deli- 
cate with  poor  circulation.  At  any  time  there  may  develop  attacks 
of  cyanosis,  which  occur  without  warning  and  which  may  be  fatal 
in  a  few  hours,  often  being  preceded  by  convulsions.  These  attacks 
may  occur  as  late  as  ten  or  twTelve  weeks  after  birth. 

Physical  Signs.  —  Inspection.—  The  breathing  is  shallow,  often 
irregular  and  at  times  almost  ceases. 

Palpation.— This  is  negative  unless  rales  are  plentiful,  when 
fremitus  may  be  felt.     Vocal  fremitus  is  absent. 

Percussion.— There  is  usually  resonance  over  the  entire  chest 
and  only  posteriorly  may  diminished  resonance  be  demonstrable. 
The  collapsed  areas  are  surrounded  by  areas  which  are  overdistended 
with  air  and  thus  resonance  is  not  much  interfered  with.  Small 
areas  of  collapse  give  no  dullness  at  all.  If  only  one  lung  is  involved 
a  difference  can  usually  be  made  out. 

Auscultation.— The  breath  sounds  are  very  feeble  and  the  expira- 
tory sound  in  particular  may  be  nearly  inaudible.  The  sounds 
may  be  rather  harsher  than  normal,  but  are  rarely  bronchial  in 
character.  The  most  marked  physical  sign  is  the  presence  of 
crepitant  rales,  the  so-called  atelectatic  crepitation,  which  are  best 
heard  usually  over  the  bases  when  the  infant,  by  flagellation  or 
otherwise,  is  induced  to  take  a  deep  inspiration. 

Diagnosis. — The  diagnosis  of  atelectasis  is  to  be  made  more  from 
the  symptoms,  the  shallow  breathing,  the  stupor,  the  asphyxia! 
attacks  and  the  debilitated  condition  of  the  infant  than  from  the 
physical  signs  which  are  likely  to  be  ambiguous  and  not  well 
defined. 

If  the  respiratory  efforts  of  the  infant  are  sufficient  to  supply 
the  needed  amount  of  oxygen  the  dangers  from  asphyxia  disappear 
and  only  the  inflammatory  complications  which  may  arise  in  the 
uninflated  lung  threaten  its  well  being.  Any  atelectatic  area 
may  become  inflated  (bronchopneumonic)  and  thus  areas  of  col- 
lapse and  bronchopneumonia  may  be  present  in  the  same  lung. 
Pneumonia  in  an  atelectatic  lung  is  not  easy  of  recognition.  The 
presence  of  crepitant  and  subcrepitant  rales,  impaired  resonance 
and  the  absence  of  respiratory  sounds,  accompanied  by  dyspnea  and 
ineffectual  cough,  all  speak  of  an  inflammatory  condition.  The 
percussion  note  may  be  vesiculotympanitic  and  auscultatory  signs 
of  consolidation,  such  as  bronchial  breathing  and  bronchophony 
may  be  inaudible  because  of  the  diminished  respiratory  excursion. 


254  DISEASES  OF  THE  RESPIRATORY  TRACT 

Differential  Diagnosis.— A  number  of  conditions  must  he  con- 
sidered in  the  differentiation  of  atelectasis,  the  more  important 
of  which  are  the  following: 

General  debility  with  quantitative  and  qualitative  lack  of  develop- 
ment attended  with  impaired  respiratory  cardiac  and  digestive 
functions.  This  is  commonly  associated  with  lack  of  development 
of  the  thoracic  wall  and  a  tendency  to  collapse  on  the  part  of  the 
costal  cartilages,  and  a  poorly  developed  respiratory  musculature. 

Cerebral  injury  associated  with  hemorrhage  is  one  of  the  most 
difficult  pathological  conditions  to  differentiate,  because  of  the 
tendency  toward  involvement  of  the  respiratory  centers,  more 
especially  in  basilar  hemorrhages.  A  careful  inquiry  should  be 
made  for  a  history  of  opisthotonos  and  clonic  contractions  of 
the  extremities  or  facial  muscles. 

Hyperplasia  of  the  thymus  and  occasionally  the  thyroid  gland, 
with  associated  stridulous  respiration,  retraction  of  the  diaphragm 
and  local  physical  findings  must  be  differentiated.  When  the  chin 
is  brought  down  upon  the  chest  respiration  becomes  more  difficult 
and,  in  turn,  is  made  easier  if  the  head  is  bent  back. 

Aspiration  of  foreign  matter  or  food  with  lack  of  expulsitory 
effort  resulting  in  cyanosis  may  lead  to  error  in  diagnosis. 

Underfeeding,  with  secondary  asphyxia. 

Congenital  diaphragmatic  hernia. 

The  differential  diagnosis  of  this  condition  is  based  on  the  fact 
that  the  abdominal  organs  containing  air  enter  the  pleural  cavity, 
thus  giving  rise  to  physical  signs  of  pneumothorax.  In  addition, 
the  following  signs  are  presented:  Respiratory  movements  on  the 
affected  side  are  absent  or  less  marked  than  normal,  and  there  is 
usually  bulging  of  the  thoracic  wall  on  the  same  side;  pectoral 
fremitus  is  slight  or  absent  and  the  percussion  note  is  deep  and  loud 
and  in  some  cases  tympanitic.  Not  infrequently  succussion  sounds 
can  be  elicited.  The  normal  breath  sounds  are  absent  over  the 
affected  area  and  the  heart  is  found  displaced  to  the  right.  More- 
over, these  findings  change  with  a  change  in  the  position  of  the 
patient.  From  the  foregoing  it  will  be  seen  that  the  findings  of 
percussion  and  auscultation  are  very  important  but  variable,  as 
they  depend  entirely  on  the  amount  of  air  or  semisolid  material 
contained  in  the  abdominal  organs  present  in  the  pleural  cavity. 

Radiographic  examination  is  of  special  value  in  differentiating 
atelectasis  pulmonum,  hyperplasia  of  the  thymus  and  diaphragmatic 
hernia. 

Prognosis. — This  depends  upon  the  degree  of  atelectasis  which 
in  turn  usually  depends  upon  the  degree  of  debility  of  the  child. 
When  accompanied  by  attacks  of  asphyxia  and  cyanosis  which 
appear  with  frequency  during  the  first  two  weeks  of  life,  the  out- 


AFFECTIONS  OF  THE  BRONCHI  AND  OF  THE  LUNGS     255 

look  is  had,  despite  the  institution  of  proper  treatment,  as  these 
attacks  commonly  result  fatally.  In  favorable  cases  they  become 
less  frequent  and  finally  cease.  Pneumonia  in  atelectatic  areas 
often  leads  to  a  fatal  issue. 

Infants  who  have  suffered  from  congenital  atelectasis  may 
remain  in  delicate  health  for  a  long  time,  although  many  ultimately 
recover  completely. 


Fig.  153. — Diffu.se  congenital  atelectasis. 


Treatment.— The  physical  condition  of  these  weaklings  is  often- 
times so  precarious  that  undue  roughness  in  the  application  of 
restorative  measures  can  work  infinitely  more  harm  than  they 
may  do  good,  and  so  it  must  be  remembered  that  the  less  the 
manipulation  necessary  to  overcome  the  cyanotic  attacks,  the 
less  is  the  danger  of  injuring  the  infant  at  this  critical  time  either 
by  overstimulation  mechanically  or  by  medication.  The  object  of 
treatment  is  directed  toward  the  expansion  of  the  lungs  through 
deep  breathing.  This  is  done  by  crying,  and  if  the  child  does  not 
cry  strongly  every  day,  it  should  be  made  to  do  so.     In  the  mild 


256 


DISEASES  OF  THE  RESPIRATORY  TRACT 


cases  cutaneous  stimulation  is  sufficient,  the  child  being  very 
gently  spanked  thrice  daily  for  fifteen  or  twenty  times,  thus  tending 
to  expand  the  collapsed  portions  of  lung  and  to  expel  mucus  from 
the  bronchi.  The  mustard  bath  is  made  by  adding  one  tablespoon 
of  powdered  mustard  to  one  gallon  of  water  at  a  temperature  of 
100°  to   105°   F.     Alternate  immersions  in  warm  water  with   a 


Fig.  154. — Incomplete  diaphragmatic  hernia  (case  of  Dr.  Irving  Stein).  Roent- 
genogram taken  three  and  six  hours  after  ingestion  of  bismuth.  Stomach  and 
bowel  in  chest. 


temperature  of  104°  F.  and  cool  water  of  95°  F.  may  be  tried, 
always  beginning  and  ending  with  the  warm  immersions.  These 
may  be  repeated  at  intervals  as  indicated  by  the  physical  condi- 
tion of  the  infant.  The  objects  of  the  bath  are  the  diversion  of 
the  blood  from  the  lungs  to  the  cutaneous  vessels,  and  expansion 
of  the  collapsed  areas.     Expansion  of  the  collapsed  lungs  is  much 


AFFECTIONS  OF  THE  BRONCHI  AND  OF  THE  LUNGS      257 

easier  during  the  first  few  days,  the  difficulty  of  doing  this  increas- 
ing proportionally  with  the  length  of  time  elapsing  since  birth. 

The  infant  should  not  be  allowed  to  lie  quietly  in  one  position, 
but  its  position  must  be  changed  frequently  and  the  child  picked 
up  several  times  a  day.  Particularly  where  many  infants  are 
housed  with  but  little  individual  attention  atelectasis  is  seen  most 


Fig.  155. — Incomplete  diaphragmatic  hernia  (case  of  Dr.  Irving  Stein).  Roent- 
genogram taken  soon  after  death  with  postmortem  injection  of  bismuth  in  the  bronchi. 
Only  lower  lobe  of  right  lung  admitted  the  bismuth  emulsion.  The  gas  distention 
of  the  stomach  and  bowels  here  beautifully  portrays  the  extent  of  eventration. 


frequently.     The   further   treatment   should    be   similar   to    that 
advised  for  attacks  of  cyanosis. 

As  the  temperature  is  so  often  subnormal,  these  children  must  be 
kept  warm,  either  by  being  surrounded  with  hot-water  bottles  or 
else  kept  in  some  form  of  heated  bed.  The  feeding  of  these  children 
is  an  important  problem  (see  chapter  on  Feeding).  It  is  essential 
to  increase  the  general  nutrition  in  order  to  increase  the  function 
17 


258  DISEASES  OF  THE  RESPIRATORY  TRACT 

of  the  respiratory  center  and  muscles.  Aside  from  this,  it  is  improb- 
able that  increased  feeding  as  recommended  by  Budin  is  of  any 
direct  value  as  a  therapeutic  measure. 

During  attacks  of  asphyxia,  oxygen  inhalations  are  recommended, 
and  are  valuable  when  the  infant  can  be  made  to  inspire,  a  tank 
being  kept  in  close  proximity  to  the  infant's  bed.  Other  measures 
of  resuscitation  mentioned  under  asphyxia  (see  Cyanosis)— cuta- 
neous stimulation  and  artificial  respiration,  or  even  the  use  of  forcible 
means  of  inflating  the  lung  with  a  catheter  in  the  trachea— may 
be  necessary  but  their  danger  must  not  be  underestimated.  The 
use  of  drugs  hypodermatic-ally,  such  as  camphor,  caffeine,  atropin, 
etc.,  is  not  of  much  value.  Aromatic  spirits  of  ammonia  in  one- 
half  to  three-drop  doses,  well  diluted,  is  worth  trying. 

CONGESTION  AND  INFLAMMATORY  CHANGES  OF  THE 

LUNGS. 

Congestion  of  the  Lungs.— Congestion  of  the  posterior  lower 
portions  of  the  lung  most  commonly  results  from  long-continued  rest 
without  change  of  position,  congenital  or  other  anomalies  of  circu- 
lation. At  first  there  may  be  extravasations  of  serum  or  blood  in 
the  alveoli  and  later,  especially  in  the  greater  degree  of  congestion, 
tissue  infiltration. 

Clinically,  the  condition  is  manifested  by  disturbances  of  respi- 
ration, shallow  breathing  and  asphyxial  attacks.  The  impairment 
of  resonance  and  auscultatory  findings  may  be  confounded  with 
those  of  atelectasis  or  inflammations.  The  findings  are  usually 
bilateral  and  in  dependent  parts;  these  facts  aid  in  the  differential 
diagnosis.  They  develop  post  partum  thereby  differing  from 
atelectasis  and  are  primarily  associated  with  fever. 

Congenital  Pneumonia. —That  congenital  pneumonia  may  exist 
seems  to  be  well  substantiated,  although  the  number  of  cases 
reported  in  which  the  infection  was  hematogenous  and  transmitted 
by  way  of  the  placenta  is  small. 

Infection  of  the  fetus  may  also  occur  through  infected  amniotic 
fluid  before  labor.  However,  when  it  is  the  result  of  the  aspira- 
tion of  infectious  material  during  the  passage  through  the  birth 
canal,  these  cases  must  be  classed  as  extra-uterine  pneumonia. 

Post-natal  Pneumonia.— Etiology.— Bronchitis  during  the  first 
few  days  of  life  may  be  the  result  of  aspiration  of  infectious  material, 
or  it  may  accompany  a  general  septic  infection.  The  fact  that  the 
vaginal  secretion  always  contains  microorganisms  offers  every 
opportunity  for  infection,  should  aspiration  occur  during  the 
infant's  passage  through  the  birth  canal.  Infection  of  the  bronchi 
may  reach  the  child  from  an  infected  mother  or  attendant,  or  from 


CONGESTIOX  AND  INFLAMMATORY  CHANGES  OF  LUNGS    259 

a  third  person  through  the  agency  of  feeding  utensils,  spoon-,  or 
other  articles.  Infections  in  the  upper  air  passages  may  spread 
by  direct  extension  to  the  deeper  structure  of  the  respiratory 
passages  and  there  occasion  a  bronchitis  or  a  bronchopneumonia. 

Atelectatic  areas,  so  common  in  the  lungs  of  the  premature  or 
weakling,  and  the  frequency  of  aspiration  of  food  or  vomitus  in 
the  debilitated  favors  the  occurrence  of  pneumonic  inflammation. 
The  richness  of  the  atelectatic  portions  of  lung  in  blood  and  tissue 
fluids  make  them  a  most  favorable  medium  for  the  multiplication 
of  the  invading  bacteria. 

The  organisms  found  in  the  bronchopneumonias  of  early  life  are 
the  pneumococcus  and  staphylococcus  most  commonly,  less  fre- 
quently the  Bacillus  coli,  the  streptococcus  and  the  influenza 
bacillus. 

Meyer1  emphasizes  the  fact  that  the  "grippe"  with  respiratory 
involvement  may  cause  a  surprisingly  extensive  infection. 

Pathology.— In  the  majority  of  cases  both  lungs  are  involved, 
the  parts  most  frequently  affected  being  the  lower  posterior  portions. 
The  principal  lesion  is  an  inflammation  of  the  walls  of  the  bronchi, 
and  the  walls  of  the  alveoli  surrounding  the  bronchi.  Micro- 
scopically before  section  there  is  often  no  visible  evidence  of  con- 
solidation, and  seemingly  all  of  the  lung  can  be  inflated.  The  walls 
of  the  bronchi  and  alveoli  are  thickened  and  infiltrated  with  round 
cells.  The  involved  alveoli  are  filled  with  an  exudate  which  is  at 
first  composed  of  desquamated  epithelial  cells  and  later  of  leuko- 
cytes. On  section  there  are  seen  grayish-red  or  yellowish-gray 
areas  which  correspond  to  the  cut  bronchi  and  the  surrounding 
peribronchitis.  From  the  cut  bronchi  the  fluid  contents  exude, 
composed  of  epithelium,  pus  cells  and  mucus.  Many  of  the  smaller 
bronchi  become  occluded  by  the  excessive  exudate  and  collapse 
of  the  contributory  alveoli  follows.  The  collapsed  portions  arc 
depressed  beneath  the  surface  of  the  surrounding  lung  and  are  of 
a  beefy-red  color. 

In  some  cases,  particularly  in  those  instances  where  the  strepto- 
coccus is  the  causative  organism,  the  inflammation  may  be  of  a 
hemorrhagic  nature.  In  these  cases  the  bloodvessels  of  the  affected 
areas  are  deeply  congested,  the  lung  tissue  is  studded  with  small 
hemorrhagic  patches  whose  size  varies  from  that  of  the  head  of  a 
pin  to  several  centimeters  in  diameter,  the  latter  being  true  infarcts. 
They  are  distinguished  from  the  zone  of  congestion  that  surrounds 
them  by  their  projecting  above  the  surrounding  tissues,  their  dark 
color  and  their  durability.  On  section  they  are  of  triangular  shape 
with  the  apex  more  or  less  deeply  in  the  lung  substance.     They 

1   IYUt  den  Hospitalismua  der  Sauglinge,  Berliu,  19 


260 


DISEASES  OF  THE  RESPIRATORY  TRACT 


are  seen  particularly  in  the  lower  lobes.  The  mucous  membrane 
of  the  large  and  small  bronchi  is  the  seat  of  a  catarrhal  inflammation 
with  round-cell  infiltration. 

Death  in  the  case  of  these  prematures  and  weaklings  is  not 
always  the  result  of  the  virulence  of  the  invading  organism  but 
may  be  attributed  rather  to  mechanical  phenomena  secondary  to 
the  involvement  of  the  lung.  Because  of  the  excessive  amount  of 
exudate  and  intraparenchymatous  hemorrhage  the  alveoli  are  filled 
with  fluid,  the  bronchial  ramifications  are  obstructed  and  the 
gaseous  exchange  limited  or  prevented  almost  entirely.  Pneumonia, 
therefore,  and  particularly  hemorrhagic  bronchopneumonia  kills 
the  premature  by  asphyxia.  In  other  instances  death  is  the  result 
of  a  true  toxemia. 

For  contrast  and  comparison  we  have  the  recent  investigations 
of  Ylppo1  who  found  that  typical  bronchopneumonic  changes  were 
very  rarely  observed  in  very  young  prematures. 

The  following  table  shows  the  frequency  of  lobular  pneumonia 
in  his  series: 

FREQUENCY  OF  BRONCHOPNEUMONIA  IN  PREMATURES. 


Death  of  the  age  of: 

Weight. 

1 
day. 

2 
days. 

3 

days. 

4  to  15 
days. 

1 
mo. 

Older. 

f  Number  of  sections. 
Under  1000  gra.     \  Bronchopneumonia 
[      in  these 

f  Number  of  sections. 
1000  to  1500  gm.    <  Bronchopneumonia 
[      in  these 

f  Number  of  sections. 
1501  to  2000  gm.    •!  Bronchopneumonia 
[      in  these 

f  Number  of  sections. 
2001  to  2500  gm.    <  Bronchopneumonia 
[      in  these 

14 
0 

24 
0 

10 
0 
2 
0 

9 
0 

18 
0 
1 
0 
1 
0 

2 

1 

9 

1 
8 
0 
1 
0 

6 

2 

6 
3 
3 
2 
1 
1 

2 
2 

10 

8 
3 
1 
2 
0 

1 

1 

14 
12 
16 
11 
12 
3 

Ylppo 's  histological  investigations  showed  that  the  broncho- 
pneumonic areas  in  prematures  were  not  at  all  as  frequent  as  the 
bronchopneumonic  areas  in  the  full  terms  in  the  first  days  of  life. 
Hess  Thaysen2  stated  that  in  newly  born  infants  dying  in  the  first 

1  Ztschr.  f.  Kinderheilk.,  1919,  20,  212. 
?  Jahrb.  f.  Kinderheilk.,  1914,  79,  140. 


CONGESTION  AND  INFLAMMATORY  CHANGES  OF  LUNGS    261 

three  days  of  life  there  could  be  demonstrated  small  bronchopneu- 
monia areas  in  42  per  cent  of  the  cases.  These  changes  are  not 
due  to  aerogenous  infection  but  to  the  aspiration  of  infected  material 
from  the  mother  during  birth.  Hochheim1  showed  that  the  vaginal 
secretion  and  amniotic  fluid  was  aspirated  and  demonstrated  the 
presence  of  foreign  bodies,  as  squamous  epithelium,  fatty  bodies, 
meconium  and  lanugo  hairs  in  the  lung  alveoli. 

Symptoms.— The  onset  is  most  often  insidious  in  the  weakly 
new  born.  At  first  there  is  noticed  possibly  a  slight  nasal  dis- 
charge and  a  cough  of  varying  severity.  Soon  increased  frequency 
of  respiration  makes  its  appearance  accompanied  by  dilatation  of 
the  alse  nasi.  The  cough  in  the  more  mature  becomes  worse  and 
the  respiration  increases  to  60  or  80  per  minute.  Now  and  again 
slight  attacks  of  cyanosis  occur,  which  in  the  severe  cases  are 
correspondingly  more  marked.  There  is  great  restlessness  in 
older  infants  with  inability  to  sleep,  and  the  cyanosis  becomes 
continuous.  Convulsions  occur  with  more  or  less  frequency,  while 
the  temperature  may  be  slightly  elevated  or  may  be  subnormal 
even  in  the  severest  cases.  There  is  a  marked  loss  of  weight,  the 
stools  become  dyspeptic,  and  greenish  with  mucus  and  undigested 
particles.     The  prostration  may  be  extreme. 

There  is  often  a  singular  lack  of  symptoms  and  the  disease  may 
go  unrecognized.  The  respirations  range  from  40  to  60  or  even 
80  to  100  per  minute,  but  are  usually  not  labored,  the  pulse-rate  is 
increased  to  140,  160  or  may  be  uncountable;  the  cough  may  be 
absent  entirely,  and  there  is  often  apathy  and  even  deep  stupor. 
The  course  in  these  infants  is  usually  acute,  either  immediate 
improvement  or  death  occurring. 

The  severity  of  these  early  symptoms  is  to  be  explained  either 
on  the  basis  of  the  sudden  intense  congestion  of  the  small  alveoli 
interfering  with  the  bronchopulmonary  apparatus  almost  as  much 
as  does  consolidation,  or  their  severity  may  be  due  to  the  intensity 
of  the  infection. 

Physical  Signs.— The  usual  physical  findings  of  a  bronchitis 
or  bronchopneumonia  are  often  lacking  or  only  suggested  in  the 
pulmonary  inflammation  of  the  premature  and  debilitated,  espe- 
cially when  the  involved  areas  are  small  in  size.  This  is  due  to  the 
fact  that  the  respiratory  efforts  are  weak  and  their  amplitude 
small.  In  addition  it  is  often  the  atelectatic  portion  of  the  lung 
which  is  involved  and  if  this  is  situated  centrally  the  air  may  fail 
to  gain  access  to  it. 

On  inspection  there  is  seen  more  or  less  marked  dyspnea,  with 
inspiratory  retraction  of  the  lower  ribs;    the  face  may  be  pale  or 

1  Path.  Anat.  Arbeiten,  Berlin,  1903  (Hirschwald) . 


262  DISEASES  OF  THE  RESPIRATORY  TRACT 

cyanosed;  cough  if  present  is  frequent,  short  and  non-productive. 
Palpation  may  reveal  nothing.  Evidence  of  consolidation  such 
as  increased  resistance  may  be  entirely  lacking. 

Percussion  may  give  indication  of  consolidation  if  impaired 
resonance  or  slight  dulness  is  demonstrable,  but  this  occurs  only 
in  the  presence  of  massive  involvement.  Occasionally  the  note 
over  the  whole  posterior  chest  may  tend  toward  the  tympanitic. 

Auscultation  usually  offers  the  most  reliable  findings.  The 
breath  sounds  are  often  entirely  absent  over  collapsed  areas  or 
the  respiratory  sounds  are  weak  and  possibly  higher  pitched  than 
normal.  In  other  instances  the  breathing  is  exaggerated,  and 
bronchial  in  character.  Probably  the  most  characteristic  finding 
of  pneumonia  in  these  infants  is  the  occurrence  of  fine  sibilant  or 
moist  rales.  These  are  often  heard  behind  over  the  lower  lobes 
and  are  the  most  distinctive  sign  of  the  disease.  The  voice  sounds 
are,  as  a  rule,  unchanged. 

Diagnosis.— Pneumonia  may,  in  these  infants,  be  easily  con- 
founded with  atelectasis.  If  the  premature  infant  is  strong  and 
possesses  a  loud  cry,  congenital  atelectasis  may  be  excluded;  in 
the  weak  the  latter  condition  is  most  commonly  present  and  the 
physical  signs  of  pneumonia  are  absent.  It  must  be  remembered 
that  the  two  conditions  may  exist  side  by  side  in  the  same  infant. 
It  may  be  necessary  to  make  the  infant  cry  or  breathe  deeply  by 
mechanical  irritation  in  order  to  bring  out  the  various  abnormal 
sounds.  A  careful  study  of  the  history  from  birth  may  be  of  great 
assistance. 

Prognosis.— If  the  inflammation  complicates  infection  in  the  upper 
air  passages,  such  as  rhinitis  or  bronchitis,  the  outlook  is  better 
than  in  primary  pulmonary  infections.  Mixed  infections  with 
the  influenza  bacillus,  staphylococci  and  streptococci,  offer  a  more 
serious  prognosis  than  primary  pneumococcus.  Involvement  of  a 
large  portion  of  both  lungs  or  an  extremely  weakened  condition  of 
the  infant,  both  militate  strongly  against  recovery.  The  younger 
the  infant  the  shorter  the  intra-uterine  life  the  higher  the  mortality 
and  when  hypothermia  exists  death  usually  occurs  soon.  Cases 
which  run  their  course  with  little  or  no  temperature  are  usually 
fatal,  probably  because  they  occur  in  infants  who  are  very  feeble, 
of  low  vitality,  with  limited  resistance  to  infection. 

Treatment. — Prophylaxis.— The  prevention  of  pneumonia  in  the 
premature  requires  that  the  little  weaklings  shall  be  protected 
against  infection  from  every  source.  The  lungs  are  most  frequently 
the  site  of  bacterial  invasion,  as  there  the  organism  finds  a  most 
favorable  medium  for  its  growth.  In  the  adult  there  exist  at  the 
entrance  to  the  respiratory  tract  defensive  agents  capable  of  stopping 
the  invading  bacteria  but  in  the  premature  these  defenses  are 


CONGESTION  AND  INFLAMMATORY  CHANGES  OF  LUNGS    2G3 

absolutely  rudimentary  and  consequently  offer  but  slight  impedi- 
ment to  the  entrance  of  pathogenic  germs  (Delestre1). 

The  transmission  of  respiratory  infections  occurs  by  means  of 
infected  hands  or  other  objects  or  through  the  medium  of  air. 
No  one  suffering  from  any  infection  of  the  nasal  or  respiratory 
passages  should  handle  the  infant.  If  the  mother  is  affected  with 
a  coryza  or  bronchitis  she  should  take  care  that  her  hands  are  not 
<  ontaminated  with  nasal  or  bronchial  secretions  and  that  she  doc-, 
not  breathe,  or  especially  cough,  in  the  face  of  the  infant.  A  mask 
must  be  worn  by  the  nurse  or  mother  if  she  has  a  respiratory  tract 
infection.  In  institutions  where  many  babies  are  taken  care  of  by 
one  nurse,  the  hands  of  the  attendant  should  be  washed  before  the 
handling  of  each  baby.  Isolation  of  the  premature  should  be 
practised  if  respiratory  affections  exist  among  the  other  members 
of  the  family,  or  in  the  common  wards  if  the  infant  is  in  an  institu- 
tion. Only  if  the  attendants  are  thoroughly  trained  in  the  principles 
of  aseptic  nursing  is  it  safe  to  leave  the  infant  in  close  proximity  to 
others  suffering  from  respiratory  affections.  These  of  all  infections 
are  hardest  to  prevent.  All  utensils  should  be  individual  and  should 
be  sterilized  before  use;  feeders,  spoons,  glasses,  nipples,  bottles, 
stomach  tubes,  etc.,  must  all  be  boiled  before  they  touch  the  child 
or  its  food.  The  French  insist  on  the  restricted  use  of  the  incu- 
bator in  the  management  of  premature  and  weak  infants  when  the 
closed  type  is  used,  and  believe  that  their  success  in  the  handling 
of  prematures  depends  upon  the  fact  that  they  remove  them  from 
the  closed  incubator  as  soon  as  the  body  temperature  reaches  37°  C, 
and  their  vitality  permits.  As  soon  as  these  babies  can  be  removed 
from  the  incubators  they  are  kept  in  large,  well-ventilated  rooms, 
which  are  not  overheated.  They  should  be  given  the  benefit  of 
open  air  and  sunshine  as  their  development  warrants.  In  favor 
of  the  open-air  treatment  is  the  fact  that  most  of  the  late  deaths 
occur  during  bad  weather.  The  mortality  drops  with  improved 
atmospheric  conditions. 

General  Treatment.— The  treatment  of  pneumonia  is  preeminently 
that  of  watchful  expectancy,  and  overtreatment  must  he  avoided, 
as  these  feeble  infants  are  unable  to  withstand  overmanipulation 
or  stimulation.  As  a  rule,  pneumonia  in  robust  infants  is  an  acute 
self-limited  disease,  but  in  premature  infants  the  course  is  apt  to 
be  somewhat  subacute  without  the  tendency  to  limitation.  The 
indications  in  the  treatment  are  to  support  the  heart  and  conserve 
the  strength.  The  feeding  problem  is  difficult  at  any  time  in  the 
premature  and  during  an  attack  of  pneumonia  it  becomes  doubly 
difficult. 

1   Ktudc  sur  les  infect.  des  prematures,  These  de  Paris,  1901. 


264  DISEASES  OF  THE  RESPIRATORY  TRACT 

The  hygiene  of  pneumonia  requires  that  the  child  receive  plenty 
of  fresh  air,  and  to  insure  this  in  an  incubator  of  the  closed  type 
is  difficult.  The  use  of  the  open  type  in  part  overcomes  this  diffi- 
culty. The  position  of  the  child  should  be  changed  frequently  in 
order  to  obviate  any  tendency  to  hypostasis.  If  the  sick  infant 
has  been  housed  in  a  closed  incubator  with  questionable  ventilation 
it  should  be  removed  to  an  open,  well-heated  room,  and  placed  in  a 
properly  warmed  crib  or  incubator  bed.  The  prime  indication  is 
for  the  promotion  of  elimination  and  sufficient  administration  of 
inert  fluid.  Stimulation  of  the  respiratory  tract  is  best  accom- 
plished by  mild  counterirritation  to  the  chest  and  the  use  of  hot 
applications  to  the  extremities.  The  use  of  drugs  such  as  cardiac 
and  respiratory  stimulants  is  not  to  be  regarded  with  favor  but 
strychnine  sulphate  in  ^fa  grain  (0.00012  gm.)  doses,  or  atropine 
sulphate  in  yww^  to  3- 0V0  Sram  (0.00006  to  0.00002  gm.)  doses  given 
hypodermically  may  be  of  some  help.  The  use  of  whisky  or  brandy 
is  permissible  in  quantities  varying  from  3  to  10  drops  every  two  or 
three  hours  depending  upon  the  indications.  Aromatic  spirits  of 
ammonia  in  1  to  5-drop  doses  is  one  of  the  best  stimulants  at  our 
command.  Both  the  whisky  and  the  ammonia  should  be  given 
well  diluted  in  at  least  8  parts  of  water.  In  cases  of  emergency,  of 
sudden  heart  failure  or  of  weakness  accompanying  a  sudden  fall 
in  temperature,  the  use  of  camphor-in-oil  2  to  10  minims  to  the 
dose  given  hypodermically  will  be  found  to  be  a  rapidly  acting, 
reliable  heart  and  respiratory  stimulant. 

If  the  infant  shows  a  marked  rise  in  temperature  the  use  of 
hydrotherapy  may  be  considered.  Temperatures  up  to  103°  F.  are 
well  borne,  and  do  not  require  interference.  As  a  general  thing 
the  temperature  tends  to  remain  subnormal  in  these  weaklings 
and  cool  or  even  tepid  baths  must  be  avoided  and  instead  warm 
or  hot  mustard  baths  resorted  to.  Even  if  there  is  an  excessive 
amount  of  fever,  should  it  be  accompanied  by  a  cold  surface,  feeble 
pulse  and  shallow  respirations,  cold  is  contraindicated.  The  best 
hydrotherapeutic  measure  used  for  the  reduction  of  an  unduly  high 
temperature  is  the  tepid  pack.  The  use  of  cold  baths  or  packs  is 
probably  never  justified  in  the  premature  or  weak  infant.  The 
temperature  of  the  tepid  bath  may  range  from  100°  to  105°  F., 
depending  upon  the  condition  of  the  child. 

The  treatment  of  attacks  of  collapse  with  cyanosis,  which  are  so 
frequent  in  the  atelectatic  prematures,  should  be  prompt.  The 
infant  should  be  immediately  placed  in  a  mustard  bath  (one  tea- 
spoonful  of  powdered  mustard  mixed  with  one  gallon  of  tepid 
water  being  of  sufficient  strength),  of  about  102°  to  106°  F.  together 
with  gentle  massage.  Respiratory  and  cardiac  stimulants  may  be 
needed.     Oxygen  should  be  administered  continuously. 


CONGESTION  AND  INFLAMMATORY  CHANGES  OF  LUNGS     265 

Disturbance  of  the  nervous  system,  occasionally  so  prominent 
in  older  and  stronger  children,  is  not  marked  in  the  premature 
during  a  pneumonic  process.  When  present  mild  hydrotherapy 
offers  the  best  results. 

The  use  of  the  coal-tar  products  is  contraindicated. 

The  diet  is  an  extremely  important  part  of  the  treatment  of 
pneumonia  and  will  he  considered  under  "The  Feeding  of  the 
Premature." 

Frequent  changes  at  regular  intervals  of  the  infant's  position  in  its 

bed  arc  imperative  to  successful  care  of  the  pneumonias  in  the  premature. 


CHAPTER   XL 
DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT. 

A.  DISEASES  OF  THE  ORAL  CAVITY. 

Sprue  (Thrush,  Soor  or  Mycotic  Stomatitis).—  Etiology.— Prema- 
ture infants,  weaklings  and  more  especially  those  suffering  from 
nutritional  disturbances  are  subject  to  this  affection.  It  occurs 
only  where  a  lesion  of  the  mucous  membrane  is  present.  The 
abrasions  of  the  epithelium  may,  however,  be  very  slight  and  in 
the  premature  is  usually  caused  by  wiping  out  of  the  mouth  or 
through  other  mechanical  injury.  The  source  of  infection  is  very 
commonly  from  the  nipple.  However,  it  may  be  carried  into 
the  mouth  through  utensils  or  soiled  pledgets. 

Symptoms.— The  importance  of  thrush  is  probably  always 
secondary  and  its  significance  above  all  symptomatic.  It  is  improb- 
able that  thrush  itself  may  cause  a  general  serious  infection.  It 
may  be  an  indicator  of  a  serious  general  affection  or  an  essentially 
lowered  resistance;  not  infrequently  it  is  seen  in  those  apparently 
in  good  health.  In  the  premature  it  sometimes  invades  the  esopha- 
gus, and  it  has  been  described  as  invading  the  blood  stream.  In  the 
more  robust  premature  infants  it  is  usually  seen  as  small  white 
punctiform  and  flat  eruptions  on  the  tongue,  gums  and  inside  of 
the  cheeks.  In  infants  with  lowered  vitality  it  may  assume  the 
form  of  extensive  membrane  covering  the  whole  buccal  cavity. 
The  latter  is  especially  true  where  it  accompanies  septic  diseases. 
In  the  severe  forms  it  is  also  frequently  associated  with  Bednar's 
aphthae. 

Usually  the  most  serious  symptom  is  the  inclination  on  the 
part  of  the  infant  to  refuse  its  food.  However,  it  may  be  associated 
with  vomiting  and  as  has  been  stated,  is  frequently  a  complicating 
factor  in  the  severe  nutritional  disturbances. 

Prognosis.— While  thrush  is  usually  curable  within  a  week  in' 
the  full- term  infant,  in  the  premature,  unless  the  treatment  is 
very  carefully  undertaken,  the  traumatism  in  the  course  of  local 
applications  may  cause  new-  local  lesions  which  become  readily 
infected,  thus  frequently  prolonging  the  course  of  the  disease. 

Treatment.  —  Prop hy la xis. — Thrush  being  due  to  lack  of  cleanli- 
ness and  trauma,  these  two  factors  should  by  all  means  be  avoided, 
and  every  effort  made  to  avoid  trauma  of  the  mucous  membrane  in 


DISEASES  OF  THE  ORAL  CAVITY  267 

the  first  care  of  the  mouth  of  the  new  born.  It  is  not  contagious 
and  if  the  proper  prophylactic  means  are  observed  in  the  daily 
routine,  it  should  not  be  spread  from  one  infant  to  the  other.  In 
the  breast-fed  the  mother's  nipples  must  be,washed  with  a  saturated 
solution  of  boric  acid  and  moistened  with  one-half  strength  alcohol, 
which  should  be  allowed  to  evaporate  from  the  nipples  before  nurs- 
ing. In  the  bottle-fed  the  nipples  and  bottles  should  be  carefully 
boiled  after  each  nursing,  and  only  such  nipples  should  be  used 
as  can  be  completely  everted  so  that  both  the  inside  and  the  outside 
can  be  thoroughly  cleansed,  following  which  they  should  be  pre- 
served in  a  borax  solution  of  one  ounce  to  a  pint  of  water.  The 
nurse  should  use  every  precaution  in  the  care  of  the  hands,  dress 
and  all  objects  which  may  be  carried  between  the  crib-. 

Local  Treatment. — Every  form  of  local  treatment  must  be  care- 
fully and  gently  applied  so  as  not  to  abrade  the  sensitive  mucous 
membrane.  Gently  sponging  the  mouth  with  a  solution  of  borax, 
10  grains  to  1  ounce  of  boiled  water  (this  is  preferable  to  boric 
acid),  using  a  very  soft  pledget  of  cotton  on  the  finger  if  the  mouth 
is  not  too  small,  otherwise  on  a  swabbing  stick  or  toothpick  after 
each  feeding,  will  usually  cure  the  disease.  Traumatism  of  the 
tender  mucous  membranes  must  be  avoided.  The  solution  may 
also  be  used  as  an  irrigation  by  allowing  it  to  come  gently  in  con- 
tact with  the  infected  surfaces,  including  the  tongue  if  involved, 
the  infant  being  turned  on  its  side  so  that  the  solution  will  flow 
out  of  the  mouth.  A  small  sucker  containing  equal  parts  of  borax 
and  sodium  bicarbonate  may  be  placed  into  the  mouth  of  larger 
infants  for  a  few  minutes  four  or  five  times  daily.  In  severe  and 
persistent  cases  it  may  be  necessary  once  or  twice  daily  to  gently 
paint  the  mucous  membrane  with  a  one-fourth  of  1  per  cent  solu- 
tion of  silver  nitrate.  Following  the  application  of  the  silver 
nitrate  2  drops  of  olive  oil  or  castor  oil  can  be  used  in  the  mouth  to 
allay  the  irritation.  Mixtures  of  honey  and  borax  as  well  as  all 
sugar  preparations  should  be  avoided. 

Internal  Treatment.— Vf here  the  infant  refuses  to  nurse  it  may  he 
necessary  to  resort  to  feeding  with  spoon,  medicine  dropper,  Breck 
feeder  or  even  to  gavage.  Every  effort  should  be  made  to  improve 
the  general  health  of  the  premature  infant  by  proper  feeding,  clean- 
liness and  good  hygienic  surroundings. 

Various  Types  of  Stomatitis.— The  term  "stomatitis"  is  applied 
to  inflammations  of  the  mucous  membrane  of  the  mouth.  In  the 
full-term  infant  three  types  are  usually  described:  the  catarrhal, 
the  aphthous  and  the  ulcerative.  The  classification  in  the  prema- 
ture is  far  less  distinct  than  in  the  full  term.  The  typo  as  most 
commonly  seen  are  the  traumatic  ulcerations,  usually  involving 
the  palate.     They  may  be  very  slight  and  superficial  or  by  second- 


268  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

ary  infection  become  serious  lesions.  The  simple  traumatic  patches 
are  usually  seen  as  yellowish,  superficial  lesions  often  covered  by 
a  slimy  membranous  film  which  can  be  easily  removed,  such  removal 
being  followed  by  small  punctate  hemorrhages.  They  are  usually 
seen  from  the  second  to  the  fourth  day  after  birth,  decreasing  in 
intensity  and  showing  a  tendency  to  rapid  healing  with  proper 
care,  usually  disappearing  within  a  week.  Even  in  the  premature 
this  variety  is  usually  harmless,  except  insofar  as  it  interferes  with 
nursing.  However,  the  dangers  of  secondary  infections  must  never 
be  overlooked. 

Etiology.— Although  the  cause  may  vary  it  is  usually  trauma  of 
the  mucous  membrane  through  cleansing  of  the  mouth.  This  is 
especially  true  of  the  handling  of  asphyxiated  and  cyanotic  pre- 
mature infants  and  follows  injury  due  to  mechanical  removal  of 
mucous  from  the  mouth.  More  serious  lesions  over  the  pterygoid 
processes  which  have  been  described  as  Bednar's  aphthae  and  which 
are  usually  due  to  more  intense  trauma  of  the  mucous  membrane 
in  the  cleansing  of  the  pharynx,  may  lead  to  more  serious  compli- 
cations. Similar  ulcerations  may  be  found  in  other  areas  where  a 
thin  mucous  membrane  is  in  close  contact  with  the  hard  bony 
structure. 

Syphilitic  stomatitis  is  not  uncommon  in  infants  suffering  from 
congenital  syphilis.  The  ulcerations  are  more  commonly  seen  about 
the  lips  unless  secondary  to  trauma. 

Gonorrheal  stomatitis  is  a  rare  condition.  The  tongue,  palate 
and  gingival  folds  are  the  seat  of  small  whitish  deposits,  usually 
appearing  on  a  non-inflammatory  base.  It  is  rarely  manifest 
before  the  fifth  or  sixth  day  after  birth.  After  one  or  two  days 
the  patches  assume  a  yellowish  color  and  become  elevated  above 
the  surrounding  tissue. 

Prognosis.— The  tendency  to  secondary  infections  and  deeper 
ulcerations  should  always  lead  to  a  guarded  prognosis,  because  of 
the  influence  on  the  future  health  of  the  infant  and  the  difficulties 
of  feeding. 

Gonorrheal  stomatitis,  while  usually  healing  without  unfavorable 
results  in  the  full-term  infant,  when  properly  treated,  is  always  a 
serious  complication  in  the  premature. 

Treatment. — Prophylactic—  This  should  consist  of  the  avoidance 
of  all  trauma  at  birth  and  the  absolute  prohibition  of  subsequent 
mechanical  cleansing  of  the  mouth,  unless  there  are  special  indi- 
cations. The  latter  is  entirely  superfluous  when  the  proper  care 
is  taken  in  the  preparation  and  administration  of  the  infant's 
food.  Infants  suffering  with  ulcerative  stomatitis  should  be 
isolated  to  impress  the  attendants  with  the  dangers  of  spreading 
the  infection  by  careless  handling. 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT         269 

Curative. — The  curative  treatment  is  the  same  as  that  described 
under  thrush  and  even  greater  care  should  he  taken  in  the  appli- 
cation of  local  treatment.  The  deeper  ulcerations  in  the  mouth 
can  be  treated  to  advantage  with  small  quantities  of  peroxide  of 
hydrogen  or  1  per  cent  potassium  chlorate  solution,  or  careful 
application  of  1  or  2  per  cent  of  nitrate  of  silver  solution.  In  all 
cases,  however,  in  the  premature  infant  the  attendant  should  not 
become  overzealous  in  the  administration  of  local  treatment, 
because  of  the  dangers  of  further  traumatizing  the  sensitive  mucous 
membrane.  The  feeding  offers  the  same  difficulties  as  in  the 
severer  cases  of  thrush  necessitating  hand  feeding  of  expressed  milk 
in  most  cases. 

In  syphilitic  and  gonorrheal  stomatitis  the  local  measures  are 
the  same  as  for  the  other  varieties  of  stomatitis.  The  general 
measures  for  the  former  are  such  as  are  described  under  the  treat- 
ment of  congenital  lues. 

Cancrum  Oris  (Noma).— Etiology.— Xo  single  microorganism  has 
proved  to  be  the  cause  of  noma.  Spirilla?  and  fusiform  bacilli  have 
been  found  (Weaver  and  Tunnicliff1)  not  only  in  the  necrotic  tissue, 
but  in  the  surrounding  healthy  parts.  Whether  these  organisms 
represent  the  primary  cause  of  the  lesion  or  only  secondary  invaders 
is  not  known.  In  other  instances  the  Bacillus  diphtheria?  alone 
has  been  found. 

Symptoms.— The  site  of  the  disease  is  usually  the  inner  side  of 
one  or  both  cheeks.  The  gangrenous  process  usually  begins  as 
a  small  inflamed,  infiltrated  area  in  the  mucous  membrane.  Local- 
ized destruction  of  tissue  follows,  and  this  process  extends  with 
great  rapidity  until  the  tissue  sloughs  away  in  masses. 

Prognosis.— The  disease  usually  occurs  in  weakly,  marantic 
infants,  who  die  from  exhaustion  and  sepsis  within  ten  days  or 
two  weeks  from  the  onset  of  the  disease.  Hemorrhage  is  rarely 
a  complication.  The  disease  is  usually  fatal  even  under  the  best 
management. 

Treatment.— Treatment  at  best  is  very  unsatisfactory.  The 
procedure  followed  in  ulcerative  stomatitis  together  with  the  use 
of  surgical  measures  affords  the  best  possibilities.  Xicoll2  reported 
a  case  which  had  resulted  in  recovery  following  the  intravenous 
injection  of  salvarsan. 

B.  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT. 

In  a  consideration  of  this  very  important  section  as  relating 
to  the  premature  infant,  we  must  recognize:     (1)  The  possibility 

1  Jour.  Inf.  Dis.,  1907,  4,  8. 
»  Arch.  Pediat.,  L911,  28,  912. 


270  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

of  congenital  malformations  and  other  prenatal  factors  which 
might  have  an  important  bearing  on  the  function  of  the  digestive 
organs;  (2)  the  lack  of  proper  physiological  development  necessarily 
present  in  the  prematurely  born,  the  importance  of  which  varies 
inversely  with  the  fetal  age;  (3)  postnatal  pathological  conditions, 
developing  in  the  gastro-intestinal  tract;  and  (4)  the  importance 
of  systemic  infections  in  their  influence  on  the  processes  of 
metabolism. 

When  the  great  importance  of  the  interdependence  of  the  second 
and  third  factors  is  recognized  even  in  the  absence  of  any  congenital 
anomalies,  we  at  once  realize  the  marked  tendency  toward  the 
development  of  disturbances  involving  the  nutrition  and  well- 
being  of  the  entire  organism.  The  use  of  the  term  "nutritional 
disturbances"  rather  than  that  of  "digestive  disturbances"  is 
beyond  any  question  more  generally  applicable  to  the  premature 
than  to  any  other  stage  of  life,  as  in  these  individuals  the  rapid 
development  of  general  nutritional  disorders  is  the  rule  following 
even  moderate  causes. 

It  must  also  be  borne  in  mind  that  all  factors  which  affect  the 
general  well-being  of  the  premature  infant,  such  as  exposure  and 
infection,  have  an  almost  direct  effect  upon  gastric  and  intestinal 
functions.  The  very  important  relationship  between  the  fetal  age 
of  the  infant  and  the  quality  of  the  food  and  the  method  of  its 
administration  will  be  emphasized  in  the  chapter  on  "Feeding." 

The  subject  of  gastro-intestinal  disturbances  in  the  premature 
infant  offers  a  far  more  complex  problem  than  do  those  of  the 
new-born  full-term  infant.  As  previously  stated,  they  require  a 
consideration  of  possible  developmental  defects,  constitutional 
anomalies,  a  low  grade  of  immunity  to  infection,  and  a  general 
lack  of  physical  and  functional  development.  The  last  two  often 
lead  to  inability  to  take  and  assimilate  the  required  food. 
Further  complications  are  due  to  the  rejection  of  the  food  or  the 
development  of  gastro-intestinal  irritation  upon  the  slightest 
indiscretion  in  feeding.  All  of  these  have  an  important  bearing 
upon  adequate  digestion,  resorption  from  the  intestinal  tract  and 
the  further  intermediary  functions. 

It  cannot  be  too  strongly  emphasized  that  the  immediate  insti- 
tution of  the  proper  hygiene,  and  the  establishment  of  the  proper 
prophylaxis  toward  the  prevention  of  nutritional  disturbance  by 
the  early  administration  of  human  milk  whenever  possible,  are 
absolutely  necessary  to  avoid  disaster.  It  cannot  be  disputed 
that  a  great  number  of  premature  infants  die,  not  because  their 
organs  lack  that  degree  of  maturity  necessary  to  proper  functions, 
but  because  of  early  neglect,  either  through  lack  of  adequate 
facilities  or  ignorance  of  exact  methods  of  feeding  and  care. 


DISEASES  OF  THE  G ASTRO-INTESTINAL  TRACT         271 

Our  acquaintance  with  the  tendency  to  the  rapid  development 
of  marasmus  in  premature  infants  leads  us  to  give  great  considera- 
tion to  the  development  of  even  the  slightest  nutritional  disturb- 
ances. It  should  become  the  rule  to  give  even  moderate  disturb- 
ances the  same  consideration  that  is  given  to  athrepsia  (ma- 
rasmus) in  the  older  infant,  which  is  always  regarded  as  making  the 
feeding  of  human  milk  imperative.  As  this  also  entails  the  feeding 
of  minimal  amounts  of  food  the  body  temperature  must  necessarily 
in  part  be  conserved  by  artificial  heat. 

I.  Functional  Insufficiencies  of  the  Gastro-intestinal  Tract 
Wholly  or  in  Part  Dependent  on  Lack  of  Development:  (a)  Diffi- 
cult Nursing. — The  causes  of  difficult  nursing  are  to  be  found  either 
on  the  part  of  the  infant  or  mother  or  both. 

The  Infant.— Various  factors  may  enter  which  may  make  nursing 
difficult  or  even  impossible.  Some  of  these  will  be  treated  under 
the  chapter  on  "Methods  of  Feeding"  (page  171).  Of  the  mal- 
formations, those  offering  the  greatest  difficulty  are  cleft  palate, 
hare-lip  and  nasal  deformities  due  to  lack  of  cartilaginous  develop- 
ment. The  tendency  to  sleep  constantly  is  often  very  perplexing. 
General  weakness  and  lack  of  muscular  development  in  the  poorly 
developed  premature  are  not  infrequently  sufficient  to  make  nursing 
impossible.  Infections  of  the  mouth  resulting  in  thrush,  stomatitis 
and  ulcerative  processes  are  always  of  serious  import.  All  condi- 
tions interfering  with  proper  respiratory  functions,  whether  due  to 
lack  of  development,  such  as  atelectasis  or  pulmonary  infections 
interfere  with  the  proper  taking  of  food.  These  are  but  a  few  of 
the  many  complications  which  may  be  cited  as  impeding  proper 
nursing. 

The  Mother.— On  the  part  of  the  mother  the  various  pathological 
conditions  of  the  nipples  and  breast  must  be  given  due  consideration. 

(b)  Anorexia.— Premature  infants  born  in  the  seventh  and 
eighth  months  rarely  show  a  disposition  to  feed  spontaneously 
during  the  first  days  of  life,  and  in  a  large  proportion  of  cases  we 
are  forced  to  administer  the  food  without  the  infant's  taking  active 
part.  Only  a  small  portion  of  the  infants  weighing  between  1000 
and  1500  gm.  are  able  to  nurse  without  assistance,  and  very  few  of 
them,  unassisted,  are  able  to  suck  with  sufficient  strength  to  take 
food  from  either  the  breast  or  the  bottle.  A  very  interesting  fact 
which  we  have  noted  in  premature  infants  weighing  under  1500 
gm.,  and  occasionally  in  even  larger  infants,  is  a  tendency  to  at 
least  attempt  to  nurse  spontaneously  during  the  first  two  or  three 
days  of  life,  during  which  they,  however,  receive  very  little  food. 
This  period  is  followed  usually  about  the  third  day  by  a  marked 
somnolence,  during  which  they  show  little  or  no  inclination  to 
purse.     This  is  usually  associated  with  a  rather  rapid  loss  in  body 


272  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

weight  due  to  underfeeding.  At  later  periods  not  infrequently 
infants  show  a  repugnance  toward  food,  which  may  follow  periods 
of  overfeeding  or  be  seen  in  the  course  of  the  gastro-intestinal  or 
systemic  infections.  At  whatever  stage  of  the  infant's  develop- 
ment anorexia  is  seen  it  must  be  given  the  gravest  consideration 
and  every  attempt  made  to  administer  food  sufficient  to  meet  the 
demands  of  the  organism.  Gavage  must  be  resorted  to  if  the  less 
drastic  methods  of  feeding  are  unavailing.  It  has  been  our  experi- 
ence that  occasionally  the  omission  of  one  or  two  feedings  with 
the  administration  of  a  one-half  strength  physiological  salt  solu- 
tion per  mouth  will  result  in  the  further  stimulation  of  the  appetite 
by  producing  thirst. 

During  this  period  the  fluids  should  be  given  in  sufficient  quan- 
tity to  meet  the  infant's  needs,  about  one-sixth  to  one-fifth  of  the 
body  weight  daily.  The  addition  of  one  to  three  drops  of  brandy 
is  often  a  beneficial  stimulant. 

(c)  Inanition  Fever.— Unquestionably  hyperpyrexia  as  seen  in 
the  first  days  of  life  and  during  the  time  when  these  infants  are 
receiving  a  minimum  of  food  need  not  necessarily  be  due  to  inani- 
tion. Many  are  undoubtedly  due  to  infection  or  toxic  products 
which  enter  the  circulation  through  the  gastro-intestinal  tract. 
The  products  of  decomposition  as  seen  during  the  period  of  change 
from  the  meconial  flora  to  the  milk  flora  can  undoubtedly  give 
rise  to  hyperpyrexia,  as  is  also  true  of  the  toxic  products  formed 
by  decomposition  of  milk.  The  effect  of  products  absorbed  from 
the  intestinal  tract  on  the  parenteral  cells,  as  well  as  the  by-products 
due  to  the  rapid  changes  seen  in  the  body  tissues,  may,  any  and  all 
of  them,  following  their  absorption,  give  rise  to  increase  in  body 
temperature.  Occasionally  one  sees  cases  of  hyperpyrexia  in  the 
premature  and  in  the  new  born  in  whom  the  high  temperature 
cannot  be  due  to  the  surrounding  artificial  heat,  and  who  make  a 
rapid  recovery  without  after-effect  by  simply  increasing  the  fluid 
intake  of  milk  or  water.  The  most  striking  cases  that  are  seen 
are  those  in  which  water  insufficient  to  meet  the  body  needs  has 
been  given. 

Treatment.— This  consists  in  the  administration  of  fluids  equal 
to  at  least  one-sixth  of  the  body  weight  of  the  infant  in  twenty-four 
hours  and  the  administration  of  food  as  per  the  rules  on  "Feeding 
of  Premature  Infants  during  the  First  Ten  Days  of  Life."  Of  equal 
importance  is  the  prevention  of  overheating  by  application  of  exces- 
sive external  heat.  When  doubt  arises  as  to  the  causative  factor 
in  so-called  "inanition  fever"  a  small  dose  of  castor  oil  (5  to  10 
minims)  together  with  a  colonic  flushing  with  a  saline  solution 
shoukl  be  given  in  addition  to  the  increase  in  the  amount  of  water 
and  human  milk  administered. 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT  273 

(d)  Vomiting.  — In  general  the  vomiting  in  the  premature  is  of 
greater  or  lesser  importance  depending  upon  its  intensity,  and  the 
result  upon  the  general  state  of  nutrition.  Vomiting  musl  be 
considered  only  as  a  symptom  and  not  primarily  as  a  disease,  and 
again  as  a  symptom  which  in  its  development  is  influenced  by 
many  factors  peculiar  to  the  premature  infant.  The  relatively 
vertical  position  of  the  stomach  in  the  sixth,  seventh  and  eighth 
months,  as  described  under  the  "Physiology  of  the  Premature 
Infant,"  is  a  factor  of  considerable  importance,  as  is  also  the  poorly 
developed  sphincter  at  the  cardia. 

Of  equal  importance  is  the  fact  that  most  of  these  infants  are 
fed  mechanically  in  amounts  theoretically  correct  for  their  weights 
and  ages.  But  these  same  quantities  may  not  agree  with  Nature's 
idea  of  sufficiency,  thereby  leading  to  a  rapid  overfilling  of  the 
stomach  through  catheter  and  other  mechanical  means  of  feeding. 
Again  the  tendency  toward  abdominal  distention  and  the  frequent 
handling  and  manipulation  of  the  infant  all  tend  to  promote 
regurgitation. 

Vomiting  persisting  beyond  the  first  or  second  week,  even  when 
varying  in  frequency  and  intensity,  is  likely  to  result  in  a  consider- 
able degree  of  undernourishment.  There  is  also  the  added  danger 
in  the  case  of  premature  infants  with  a  minimal  development 
of  reflex  irritability,  that  due  to  the  lack  of  proper  response  on  the 
part  of  the  laryngeal  reflexes,  the  regurgitated  food  may  be  aspirated 
with  resulting  sequela?,  such  as  cyanotic  spells,  asphyxia  or  even 
pulmonary  infection. 

Because  of  the  great  danger  of  underfeeding  in  the  presence 
of  small  food  intake  there  is  the  gravest  danger  of  weight  losses, 
with  the  consequent  development  of  inanition. 

Etiology.  — Previous  to  the  taking  of  food  the  infant  may  vomit 
the  various  fluids  such  as  liquor  amnii  and  blood,  which  may  have 
been  swallowed  during  labor.  These  may  easily  be  recognized 
by  their  character.  Following  the  intake  of  fluid  many  factors 
must  be  considered,  such  as  atresias  in  the  digestive  tract,  excessive 
feedings,  which  may  be  due  to  too  free  nursing  from  an  easily 
secreting  breast  by  the  older  premature  infants,  or  too  rapid  feeding 
of  large  quantities  mechanically  given  to  the  smaller  infants. 

The  dangers  of  compression  of  the  abdomen  due  to  improper 
holding  or  excessive  handling  of  the  infant  are  usually  overcome 
by  feeding  in  the  bed.  The  tendency  to  habitual  vomiting  is  not 
uncommon  in  the  first  months  of  life  in  the  premature.  This  i> 
not  infrequently  due  to  a  general  state  of  nervousness  or  a  neuro- 
pathic constitution.  According  to  Alfred  F.  Hess,  this  can  easily 
be  demonstrated  by  passing  a  catheter  and  exciting  the  pharyngeal, 
cardiac  and  pyloric  reflexes,  which  in  the  normal  child  are  but 
18 


274  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

slightly  developed,  while  in  the  neuropathic  individual  the  passage 
of  the  catheter  is  easily  noted  by  the  reflex  manifestations  following 
its  passage.  Undoubtedly  many  of  these  cases  are  true  instances 
of  pylorospasm.  That  true  cases  of  pyloric  stenosis  may  occur 
has  been  proven  beyond  doubt.  The  fact  that  these  infants  not 
infrequently  vomit  quantities  larger  than  a  single  feeding  should 
not  lead  to  the  diagnosis  of  a  hypertrophic  stenosis,  as  is  proven 
by  the  fact  that  the  stools  usually  contain  a  considerable  amount 
of  food  residue. 

The  toxic  vomiting  as  seen  in  the  infants  of  eclamptic  mothers 
and  in  the  presence  of  sepsis,  as  well  as  hematemesis,  will  receive 
further  consideration  in  the  discussions  on  these  topics.  Vomiting 
may  at  any  time  become  of  serious  moment  and  should  always  be 
given  proper  consideration.  The  relative  loss  of  food  as  foretold 
by  the  scale,  by  weighing  before  and  after  feeding,  and  after  vomit- 
ing, the  weight  curve  and  careful  observation  of  the  stools  will  give 
the  best  indications  for  therapeutic  interference. 

Treatment.— In  the  majority  of  cases  there  is  no  indication  for 
active  treatment.  The  occasional  or  even  more  or  less  regular 
"spilling"  in  the  presence  of  a  normal  gain  in  weight  and  general 
well-being  need  receive  little  or  no  attention.  However,  when 
vomiting  is  persistent  and  is  attended  by  stationary  weight,  which 
is  equivalent  to  loss  in  weight  in  older  individuals,  or  when  it  is 
associated  with  nausea  or  is  expulsive  in  character  or  contains  bile, 
blood  and  other  matter  foreign  to  the  normal  stomach  content, 
it  should  receive  prompt  and  careful  attention.  No  set  rules  for 
treatment  can  be  prescribed,  as  the  etiological  factors  in  each  and 
every  case  must  be  considered  individually.  The  following  general 
principles  of  treatment  will  in  a  great  number  of  cases  prove 
sufficient: 

1.  The  infant  should  be  subjected  to  a  minimum  of  handling. 
It  should,  whenever  possible,  be  fed  without  being  removed  from 
its  bed,  or  where  handling  is  necessary,  all  violence  should  be 
avoided. 

2.  The  recumbent  position  with  the  head  and  shoulders  slightly 
elevated  assist  in  overcoming  the  tendency  to  regurgitation  in  the 
presence  of  a  weak  sphincter  at  the  cardia. 

3.  Regulation  of  feedings  is  primarily  indicated.  This  should 
cover  first  the  number  of  feedings  and  the  interval  between  feedings, 
and  the  amount  of  the  individual  meal.  Not  infrequently  an  infant 
who  is  receiving  quantities  too  great  for  the  stomach  capacity  will 
cease  vomiting  upon  simple  reduction  of  the  size  of  the  individual 
meal.  Again  it  may  be  necessary  to  decrease  the  number  of 
feedings,  thereby  lengthening  the  intervals  between  feedings. 
Furthermore  large  meals  at  long  intervals  may  be  replaced  by 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT         275 

small  meals  at  short  intervals  with  a  very  beneficial  result.  Where 
the  infant  is  nursing  at  the  breast,  simply  reducing  the  time  allowed 
for  nursing  in  many  instances  will  accomplish  the  desired  end. 
The  same  may  he  true  as  regards  the  slower  administration  of  the 
individual  feedings  in  the  bottle-fed. 

4.  In  infants  nursing  directly  at  the  breast  where  the  shortening 
of  the  period  of  nursing  is  insufficient  to  control  the  vomiting, 
drawing  the  milk  by  expression  or  by  breast  pump  and  feeding  a 
measured  quantity  which  can  be  retained,  either  by  hand  or  catheter, 
is  often  successful. 

It  is  customary  to  start  such  feedings  by  giving  2  to  10  gm.  at 
short  intervals,  10  to  12  if  bottle  fed,  or  6  to  8  if  fed  by  catheter, 
in  twenty-four  hours,  preferably,  although  not  necessarily,  of  freshly 
drawn  milk,  following  this  by  gradually  increasing  quantities,  and 
as  soon  as  the  proper  quantity  for  growth  is  retained,  lengthening 
the  intervals,  returning  to  direct  nursing  when  the  infant's  general 
condition  allows  of  the  same.  In  the  more  severe  cases  the  human 
milk  may  be  boiled  or  a  skimmed  human  milk  should  be  used. 

Under  these  conditions  the  milk  supply  should  be  protected 
through  the  emptying  of  the  breasts  by  expression  to  prevent  their 
drying  up. 

The  question  of  even  temporary  starvation  in  the  premature 
infant  is  one  of  serious  import  and  should  only  be  practised  after 
the  most  careful  consideration,  because  of  the  rapidly  developing 
apathy  in  this  class  of  infants.  The  presence  of  so-called  "  hunger 
stools/'consisting  of  a  brownish,  stringy  mucous  substance  with 
little  or  no  food  residue,  is  as  a  danger  signal  of  almost  equal 
importance  with  loss  in  weight. 

If  the  above  suggestions  fail  to  accomplish  the  desired  end, 
rather  than  to  institute  a  starvation  diet  we  prefer  to  empty  the 
stomach  by  careful  lavage,  using  a  weak  sodium  bicarbonate  or 
saline  solution,  and  before  withdrawing  the  catheter  placing  a 
small  feeding  of  human  milk  into  the  stomach.  Lavage  is  practised 
not  so  much  with  the  idea  of  removing  any  decomposed  food 
content,  but  because  of  the  sedative  action  on  the  mucosa.  The 
dangers  of  gastric  irritation  from  repeated  introduction  of  the 
catheter  in  careless  hands  must,  however,  always  lie  remembered, 
also  the  dangers  of  promoting  cyanotic  spells,  through  the  careless 
deposit  of  fluids  in  the  pharynx  and  larynx.  In  the  infants  arti- 
ficially fed  the  problem  is  far  more  serious,  and  offers  for  it-  solu- 
tion greater  difficulties  unless  human  milk  can  be  obtained.  In 
our  own  experience  a  well-boiled  milk,  in  which  the  casein  has  been 
precipitated  as  a  fine  flocculent  curd  by  the  addition  of  rennet,  has 
given  the  best  results  when  human  milk  was  not  to  be  obtained 
(see  Preparation   of  Chymogen  Milk).     Diluting   the  milk   thus 


276  DTSEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

prepared  before  feeding,  or  skimming  before  boiling  may  also  be 
of  benefit.     Lactic  acid  milk  mixtures  may  be  used. 

(e)  Gastric  and  Intestinal  Indigestion  and  Distention.— These  may 
be  of  very  serious  consequence  in  the  premature  through  inter- 
ference with  the  respiratory  and  cardiac  functions,  and  the 
precipitation  of  cyanotic  attacks.  Although  frequently  following 
relative  overfeeding  this  need  not  necessarily  be  the  case.  Most  of 
the  factors  which  result  in  vomiting  also  predispose  to  indigestion 
and  distention.  Abdominal  distention  is  exceedingly  troublesome 
in  the  premature  infant,  but  does  not  necessarily  imply  that  indi- 
gestion is  present.  It  may  result  in  restlessness,  vomiting,  colic, 
borborygmus,  increased  respirations  and  cardiac  action,  hypo- 
thermia, cold  extremities  and  not  infrequently  cyanosis. 

While  we  have  seen  abdominal  distention  result  in  hypothermia 
it  is  equally  true  that  when  hypothermia  is  present  it  is  almost 
invariably  associated  with  impaired  digestion,  and  a  tendency  to 
cyanosis  and  syncope.  Owing  to  the  tendency  to  abdominal 
distention  there  is  the  danger  of  underfeeding  due  to  low-food  toler- 
ance. Excessive  external  heat  whether  from  the  use  of  simple 
heating  devices  or  the  more  complex  incubators  often  cause  increased 
body  temperature  and  result  in  impaired  digestion.  I  have  not 
infrequently  seen  death  result  from  a  relative  overfeeding,  due  to 
attempts  to  feed  infants  food  sufficient  for  their  needs;  but  even 
more  frequently  do  we  see  grave  catastrophes  from  underfeeding  in 
the  same  class,  with  rapidly  developing  syncope  due  to  inanition. 

Indigestion  may  be  followed  by  an  increase  in  the  number  of 
stools,  and  they  become  green  and  foamy  and  contain  curds. 
The  inability  of  the  infant  to  handle  foods  sufficient  for  its  mainte- 
nance without  the  development  of  functional  derangement  is  a 
very  grave  deficiency,  directly  dependent  upon  the  fetal  age  and 
factors  predisposing  to  prematurity  in  the  individual  case.  Less 
dangerous  are  the  cases  due  to  absolute  overfeeding  following 
early  correction  in  the  errors  of  diet,  as  are  also  the  cases  following 
indiscretions  on  the  part  of  the  wet  nurse  or  mother.  In  the  first 
few  weeks  of  life  severe  indigestion  is  often  fatal.  This  is  especially 
true  in  artificially  fed  infants.  Improper  hygienic  surroundings 
such  as  poor  ventilation,  oppressive  humidity  and  lack  of  personal 
cleanliness  may  be  factors  in  the  development  of  indigestion. 

The  role  of  intestinal  and  systemic  infections  will  be  considered 
under  their  respective  headings. 

Treatment.— In  the  treatment  correction  of  dietetic  errors  is  most 
essential,  and  this  is  especially  true  in  the  artificially  fed  premature 
infants.  It  should  always  be  remembered  that  the  correction  of 
the  mild  forms  of  indigestion  are  the  life-saving  measures.  Severe 
indigestion  has  a  high  mortality.     Stimulation  of  peristalsis  and 


DISEASES  OF  THE  GASTHO-I XTESTIXAL  TRACT         277 

thereby  emptying  of  the  intestinal  tract  is  usually  accomplished 
by  a  low-pressure  saline  enema  of  1  or  2  ounces.  In  some  Instances 
the  addition  of  1  gm.  of  glycerin  to  an  ounce  of  water  is  of  great 
assistance.  Warm  baths  with  or  without  very  gentle  abdominal 
massage  may  aid  in  increasing  the  peristalsis.  Where  the  symptoms 
are  persistent  5  to  S  drops  of  castor  oil,  1  to  5  grain-  of  sodium 
phosphate,  or  5  to  10  minims  of  milk  of  magnesia,  together  with 
3  to  5  minims  of  essence  of  pepsin  of  good  quality,  after  each  feed- 
ing, can  occasionally  be  administered  with  great  benefit.  But 
unless  the  hygiene  and  feeding  of  the  infant  are  properly  regulated 
little  permanent  good  can  he  expected.  Correction  of  dietetic- 
errors  in  the  breast-fed  is  best  accomplished  by  reducing  the  size 
and  lengthening  the  intervals  between  individual  meals  when  the 
stomach  is  very  irritable.  However,  decreasing  the  size  of  the 
feedings  is  always  associated  with  more  or  less  danger  and  where 
the  same  results  can  be  secured  by  simply  lengthening  the  intervals 
this  offers  the  best  solution.  Starvation  diet  should  under  all 
circumstances  be  avoided,  although  it  may  be  necessary  in  extreme 
cases  to  dilute  the  meals.  While  larger  infants— those  weighing 
in  the  neighborhood  of  2000  gm.— will  stand  the  reduction  of  the 
feedings  to  as  low  as  60  calories  per  kilogram,  in  the  smaller  infants 
70  to  80  calories  must  be  considered  the  danger  zone  for  even  a 
short  period  of  time.  In  the  artificially-fed  every  attempt  should 
be  made  to  obtain  human  milk  and  where  this  is  impossible  our 
best  results  have  been  obtained  by  feeding  boiled  milk,  in  which 
the  curd  has  been  finely  precipitated.  (See  Artificial  Feeding, 
page  199.) 

(/)  Diarrhea.— Constipation  is  the  exception;  loose  stools  or  a 
tendency  toward  diarrhea  in  both  the  breast-fed  and  the  artificially- 
fed  premature  infants  is  the  rule.  Therefore,  frequency  of  bowel 
movements,  especially  in  the  breast-fed  may  be  entirely  physio- 
logical and  unassociated  with  fever,  vomiting  and  other  evidences 
of  gastro-intestinal  disturbances.  However,  they  may  be  due  to 
contaminated  food  or  intestinal  infection,  and  every  case  should, 
therefore  be  carefully  studied  so  that  evidences  of  deep  lesions 
may  be  immediately  observed.  In  the  infant  nursed  by  its  mother 
the  colostrum  will  almost  invariably  result  in  frequent  bowel  move- 
ments. This  is  one  of  the  prime  reasons  in  the  selection  of  wet 
nurses,  who  have  passed  at  least  two  or  more  weeks  of  their  puer- 
perium.  The  early  milk  also  has  a  tendency  to  be  high  in  its 
carbohydrate  and  fat  content,  either  of  which  may  be  factors  in 
the  causation  of  frequent  stools.  A  gastro-intestinal  infection 
may  be  unassociated  with  fever  and  may,  therefore,  go  unrecognized 
and  be  of  serious  consequence.  Changes  in  the  mother's  environ- 
ment, when  she  is  nursing  her  own  infant,  as  is  seen  at  the  end  of 


278  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

the  puerperium  when  she  leaves  her  bed  and  changes  her  mode 
of  living,  seem  to  have  a  very  beneficial  influence  on  the  quality  of 
milk  secreted,  and  the  mother  and  baby  seem  to  adapt  themselves 
more  readily  to  each  other.  This  beneficial  change  is,  of  course, 
not  seen  where  the  baby  is  fed  by  a  wet-nurse. 

At  this  point  I  desire  especially  to  emphasize  my  experience 
with  both  mothers  and  wet-nurses  who  are  given  a  too  liberal  diet. 
While  the  average  mother  can  be  allowed  to  select  her  own  diet 
during  the  nursing  period  of  a  full-term  infant,  eliminating  such 
foods  as  may  cause  colic,  abdominal  distention  and  diarrhea  in  the 
infant,  in  the  case  of  the  premature  such  liberties  must  under  no 
circumstances  be  allowed  as  they  may  result  in  an  early  disaster, 
cyanosis  and  death  due  to  abdominal  disturbances.  Therefore, 
every  wet-nurse  should  be  made  to  adhere  strictly  to  the  limitations 
of  diet  as  prescribed  under  the  section  on  "  Diet  of  Wet-nurses" 
(page  121).  So  long  as  the  infant  is  passing  yellow  stools  of  normal 
odor,  without  symptoms  of  indigestion  and  is  gaining  in  weight,  even 
though  the  stools  may  number  five  to  eight  daily,  no  alarm  should 
be  felt,  and  the  diet  should  be  sustained. 

The  change  of  the  yellow  stool  to  a  green  color  shortly  after 
passage  is  the  normal  process  of  oxidation.  However,  the  green, 
frothy  stool  containing  small  white  curds  and  considerable  mucus 
should  always  be  considered  abnormal.  Such  stools  usually  lose 
their  normal  acid  odor,  cause  excoriation  of  the  buttocks,  and  are 
frequently  associated  with  fever.  This  is  not  infrequently  a  finding 
in  the  breast-fed  premature.  In  the  treatment  of  such  cases, 
while  the  care  of  the  infant  is  of  paramount  importance,  no  less 
important  is  the  careful  regulation  of  the  mother's  surroundings, 
mode  of  living  and  diet  and  also  her  mental  activity.  Again  every 
precaution  must  be  taken  in  reducing  the  infant's  diet,  and  the 
same  dietetic  measures  which  were  instituted  for  the  treatment 
of  indigestion  apply  to  every  case  of  diarrhea  with  abnormal  stools, 
as  they  are  almost  invariably  attendant  on  an  intestinal  indigestion 
or  infection. 

Dehydration  of  the  body  tissues  through  excessive  water  losses 
must  be  met  with  sufficient  water  administration,  so  that  a  good 
working  rule  should  lead  one  to  administer  at  least  one-sixth  of  the 
body  weight  daily  in  fluids,  in  all  cases  of  diarrhea.  Therefore, 
when  the  quantity  of  the  meals  is  reduced,  or  the  interval  lengthened, 
water  should  be  added  to  the  feedings  or  be  administered  between. 
The  normal  infant's  stool  will  form  a  water  margin  about  the  semi- 
solid mass  about  one-half  to  three-quarters  of  an  inch  in  diameter. 
When  more  water  than  this  is  lost  with  each  stool,  the  infant  must 
be  carefully  weighed  and  its  water  losses  noted  so  that  they  may 
be  compensated. 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT         279 

Tarry  stools  are  always  due  to  the  presence  of  blood,  and  abrasions 
of  the  intestinal  mucous  membrane  are  likely  to  lead  to  fatal 
infections  and  must  therefore  always  be  given  serious  consideration. 

(<7)  Constipation.— The  mechanical  causes  such  as  atresias  in 
various  parts  of  the  intestinal  tract,  or  an  imperforate  anus,  must 
be  considered  as  possible  causes.  As  has  been  previously  stated, 
diarrhea  is  far  more  common  than  constipation.  This,  however, 
does  not  mean  that  a  sluggish  lower  bowel  is  uncommon  in  the 
premature.  In  fact  the  lack  of  power  of  the  muscular  wall  and 
the  minimal  reaction  of  the  mucous  membrane  to  mechanical 
and  chemical  stimulation  are  both  important  etiological  factors 
and  are  often  associated  with  intestinal  distention.  The  first 
evidence  of  this  lack  of  response  is  often  noted  in  the  inability  of 
the  premature  infant  to  evacuate  the  meconium  which  has  accumu- 
lated in  the  lower  bowel,  and  this  may  require  mechanical  removal 
by  the  aid  of  a  small  saline  enema  or  further  irritation  with  a  soap 
or  glycerin  suppository.  If  these  means  fail,  a  single  dose  of  5  to 
8  drops  of  castor  oil  may  be  administered  without  too  great  delay, 
as  it  is  our  rule  to  start  feeding  only  after  the  first  intestinal  evacua- 
tion, so  that  the  presence  of  an  atresia  may  have  been  noted,  and 
the  meconium  removed  before  it  has  become  infected  through 
bacterial  ingestion.  The  next  stage  of  the  infant's  existence  which 
is  associated  with  constipation  is  in  the  first  few  days  of  life  when 
food  ingestion  is  insufficient  and  below  the  caloric  requirements  of 
the  infant.  In  such  instances  in  the  absence  of  other  causes  it 
may  be  considered  as  a  certain  symptom  of  underfeeding,  as  is 
the  case  at  all  times  when  "hunger  stools"  are  present.  Increasing 
the  food  judiciously  removes  the  trouble. 

As  the  infant's  digestive  function  improves  and  it  utilizes  its 
food  to  the  fullest  advantage,  constipation  may  result  from  the 
minimal  amount  of  food  residue.  The  best  evidence  of  such  a 
causative  factor  in  the  presence  of  sufficient  feeding  is  the  improve- 
ment in  general  condition  and  gain  in  weight.  In  fact,  utilizing 
their  food  perfectly,  they  have  a  tendency  to  constipation  so  long 
as  their  food  intake  is  not  in  excess  of  their  required  caloric  needs. 
Therefore,  feeding  this  class  of  infants  moderately  in  excess  of  the 
normal  caloric  needs  usually  overcomes  the  constipation. 

In  the  treatment  where  the  ability  to  digest  food  is  minimal, 
increasing  the  water  intake  is  frequently  beneficial.  Even  prema- 
ture infants  are  creatures  of  habit,  and  where  it  is  necessary  to 
assist  them  in  the  evacuation  of  their  bowels,  this  should  be  practised 
at  a  stated  hour,  once  or  twice  daily,  either  through  the  use  of  a 
saline  or  oil  enema,  non-irritating  suppositories,  or  what  is  better, 
the  tip  of  a  well-oiled  catheter.  Medication  in  the  form  of  laxatives 
administered  to  the  mother  in  the  hope  of  influencing  the  character 


2'80  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

of  the  milk,  as  well  as  drugs  administered  directly  to  the  infant  are 
more  or  less  dangerous  agents  and  should  be  avoided  whenever 
possible.  Ten  to  15  drops  of  paraffine  oil,  5  to  10  minims  of  milk  of 
magnesia  or  equal  amounts  of  castor  oil,  may  occasionally  be 
administered,  but  only  after  attempts  at  correction  by  mechanical 
irritation. 

(h)  Underfeeding.  — In  order  to  consider  this  subject  properly 
we  must  first  take  into  consideration  the  types  of  infants  with 
which  we  are  dealing,  that  is:  (1)  Healthy  premature  infants, 
and  (2)  congenitally  debilitated  infants,  either  premature  or  full- 
term.  We  must  again  divide  them  into  the  classes  of  breast-fed 
and  artificially-fed,  and  lastly,  as  to  whether  the  underfeeding 
occurs  during  the  first  days  of  life  during  the  period  when  we  may 
expect  normally  stationary  weight,  or  weight  losses,  or  at  later 
periods,  during  which  we  are  more  likely  to  see  the  development 
of  the  completed  picture  of  marasmus. 

Before  entering  upon  the  details  of  this  subject  several  factors 
which  tend  toward  the  development  of  inanition  and  marasmus  not 
directly  dependent  upon  underfeeding  must  be  considered:  (1) 
The  danger  of  an  imperfectly  developed  digestive  tract,  which 
even  in  the  presence  of  sufficient  food  may  soon  result  in  a  metabolic 
bankruptcy.  These  infants  rarely  survive  the  first  days  of  life. 
(2)  Improper  hygienic  surroundings  of  the  infant,  of  which  one 
of  the  most  important  is  the  danger  of  overheating,  thereby  inter- 
fering with  heat  regulation  and  associated  with  excessive  evapora- 
tion from  the  body  surfaces.  This  is  especially  disastrous  in  its 
effects  in  the  presence  of  decreased  humidity.  Both  of  these 
factors  predispose  to  atrophy.  Lessened  immunity  with  the  added 
dangers  of  local  and  general  infections  and  the  secondary  nutri- 
tional disturbances  are  especially  common  in  this  class  of  infants, 
as  are  the  tendencies  toward  repeated  nutritional  disturbances 
once  they  are  established.  All  of  these  factors  which  may  tend 
to  impair  the  general  nutrition  of  the  infant  will  but  serve  to  empha- 
size the  need  of  careful  observation.  It  will,  therefore,  be  seen 
that  underfeeding  may  be  a  primary  affair,  or  may  result  secondarily 
following  previous  nutritional  disturbances. 

II.  Underfeeding  in  the  Healthy  Breast-fed  Premature  Infant 
During  the  First  Days  of  Life.— This  represents  the  dangerous 
period  through  which  most  premature  infants  pass  whose  feeding 
is  delayed,  awaiting  the  secretion  of  milk  from  the  mother's  breasts. 
While  the  full-term  infant  may  pass  through  this  period  with  slight 
disadvantages  to  its  future  development,  the  life  of  the  premature 
infant  may  be  jeopardized  beyond  all  hope  of  recovery. 

It  has  been  our  experience  that  when  feeding  is  too  long  delayed 
the  infants,  unless  very  carefully  fed  in  minimal  quantities,  are 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT         28] 

subject  to  repeated  digestive  disturbances  and  secondary  infection, 
the  latter  due  probably  to  lowered  resistance.  In  the  premature 
infant  this  is  true  even  though  the  infant's  food  be  human  milk. 
How  much  more  important  is  the  avoidance  of  long  starvation  in 
those  who  are  to  be  fed  artificially,  can  easily  be  surmised.  Whereas 
the  birth  weight  in  the  average  premature  infant  is  regained  by  the 
second  or  third  week,  in  those  who  have  suffered  great  initial 
weight  losses  through  starvation  the  return  to  normal  birth  weight 
is  greatly  delayed.  It  is  surprising,  however,  to  note  what  minimal 
quantities  of  human  milk  alternated  with  water,  with  a  total 
administration  of  one-eighth  to  one-tenth  of  the  body  weight  of  fluid 
in  twenty-four  hours,  will  tend  to  prevent  great  initial  weight  loss 
during  the  first  few  days.  (See  Section  on  "Feeding  during  the 
First  Ten  Days  of  Life.") 

The  removal  to  an  institution  supplied  with  wet-nurses  or  a  wet- 
nurse  in  the  home  are  the  ideal  remedies.  Small  quantities  of  milk 
obtained  from  other  mothers  to  tide  over  the  period  of  early  lacta- 
tion when  secretion  is  delayed,  as  is  not  infrequently  the  case  where 
labor  is  considerably  before  term,  will  prevent  a  critical  condition. 
Where  the  prospects  for  human  milk  are  much  delayed,  the  anxiety 
of  the  family,  due  to  the  decrease  in  weight,  may  often  be  relieved 
by  judicious  artificial  feeding,  as  suggested  in  the  chapter  on 
Feeding.  It  is  always  the  part  of  wisdom  to  impress  the  family 
with  the  fact  that  stationary  weight  and  fluctuating  weight  are 
to  be  expected  for  a  much  longer  period  in  the  premature  than  in 
the  full- term  infant,  and  that  this  stationary  weight  curve  does 
not  indicate  a  bad  prognosis.  Artificial  feeding,  if  instituted  should 
always  be  discontinued  at  the  first  opportunity. 

In  the  congenitally  debilitated  infant,  especially  the  premature, 
human  milk  is  a  practical  necessity  for  a  low  mortality. 

Atrophy  and  marasmus  as  seen  after  the  first  days  or  weeks  of 
life  are  even  more  dangerous  than  the  evidence  of  inanition  during 
the  first  days  of  life,  because  they  are  almost  invariably  secondary 
to  previous  underfeeding,  errors  in  diet,  or  gastro-intestinal  and 
systemic  infections,  and  improper  hygienic  conditions,  which  are 
unfortunately  frequently  neglected  or  overlooked,  even  when 
attempts  to  overcome  the  conditions  are  made.  In  all  late  cases 
of  marasmus  in  the  premature,  while  removal  of  the  underlying 
factors  is  an  absolute  essential,  the  furnishing  of  the  proper  diet 
in  the  form  of  human  milk  is  of  equal  important  e. 

III.  Secondary  Digestive  and  Nutritional  Disturbances  Accom- 
panying Systemic  Infections  (Parenteral).— Just  as  digestive  dis- 
turbances result  in  lessened  immunity  to  infection,  so  do  we  find 
digestive  troubles  following  the  infections  in  the  premature,  such 
as  infections  of  the  skin,  lungs,  genito-urinary  tract,  ears  and  the 


282  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

general  septic  infections,  which  are  of  common  occurrence  in  these 
individuals.  These  secondary  conditions  are  also  likely  to  run  a 
more  severe  course  than  the  primary  nutritional  disturbances. 

Where  it  is  possible  to  keep  up  the  baby's  nutrition  by  the  proper 
administration  of  foods  during  the  course  of  an  infection,  such 
children  may  be  subject  to  little  or  no  weight  loss  in  the  milder 
types.  In  more  serious  cases  the  food  must  be  reduced  both 
qualitatively  and  quantitatively.  However,  even  in  these,  to 
avoid  catastrophes,  long-continued  underfeeding  or  starvation 
must  of  necessity  be  avoided,  and  only  in  exceptional  cases  with 
resulting  food  intoxication  must  all  food  be  withdrawn.  Such 
cases  furnish  us  with  every  indication  for  early  feeding  with  human 
milk  whenever  possible.  True  alimentary  intoxication  is  usually 
early  recognized  by  the  toxic  symptoms— facial  expression,  rapid 
respiration,  and  marked  drops  in  the  weight  curve.  In  these  cases 
temporary  complete  withdrawal  of  food  in  the  absence  of  severe 
infection  results  in  disintoxication.  In  parenteral  infections  this 
is  not  the  fact,  and  starvation  only  leads  to  a  further  reduction  in 
fighting  power  and  therefore  should  not  be  long  continued.  The 
further  treatment  of  these  cases  is  the  same  as  that  to  be  described 
under  "Infection  of  the  Gastro-intestinal  Tract." 

IV.  Infections  of  the  Gastro-intestinal  Tract  (Enteral).— No 
subject  with  which  we  have  to  deal  in  the  care  of  premature  infants 
calls  for  such  mature  judgment  as  the  care  and  treatment  of  gastro- 
intestinal infections.  In  fact  the  entire  hospital  unit  is  more 
or  less  planned  and  constructed  with  the  idea  of  prevention  and 
isolation  of  these  cases.  Our  thought  should  all  be  centered  on 
their  prevention,  since  once  they  become  established  their  course 
is  associated  with  the  gravest  dangers. 

Infections  of  the  intestinal  tract  are  secondary  in  importance 
only  to  infections  of  the  respiratory  tract.  It  is  well  known  that 
infection  of  either  of  these  systems  is  likely  to  run  rampant  through- 
out hospital  wards  unless  the  individual  cases  are  properly  segre- 
gated at  the  outset.  The  infection  may  be  spread  through  care- 
lessness in  handling  the  infant's  utensils  or  lack  in  the  care  of  the 
nose  and  mouth,  through  the  nipples  if  nursing  on  the  bottle,  or  by 
lack  of  asepsis  in  the  care  of  the  maternal  breasts.  Again  it  may 
be  spread  by  the  thermometer,  unclean  napkins,  or  it  may  be 
transmitted  by  flies  and  insects.  The  food  is  in  all  probability  the 
most  common  source  of  transmission,  and  the  milk  may  be  infected 
either  in  the  breasts  themselves  or  in  the  handling.  In  the  past 
before  our  wards  were  properly  equipped  to  care  for  premature 
infants,  doubt  as  to  the  advisability  of  instituting  hospital  treat- 
ment in  preference  to  the  home,  even  though  the  facilities  for 
general  care  were  limited,  existed  in  our  minds  with  good  reason. 


DISEASES  OF  THE  GASfRO-iNTESflNAL  TUMI  283 

All  intestinal  disturbances  must  be  considered  serious  because 
at  the  outset  it  is  impossible  to  decide  whether  we  are  dealing 
with  a  simple  indigestion  or  the  first  symptoms  of  an  infectious 
diarrhea.  Again  it  is  quite  difficult  to  determine  whether  we  are 
dealing  with  the  abnormal  activities  of  the  intestinal  flora  or  with 
pathogenic  bacteria  or  their  metabolic  products.  It  is  also  a  well- 
known  fact  that  the  normal  bacterial  inhabitants  of  the  bowels  max 
under  suitable  circumstances  either  form  toxic  products  or  pass 
through  the  frail  intestinal  wall  of  the  premature  infant  into  the 
general  circulation. 

That  we  may  have  serious  intestinal  symptoms  without  infec- 
tion is  not  to  be  denied.  On  the  other  hand,  however,  we  have 
the  findings  of  Schabort1  who  was  able  to  isolate  diplococci  and 
staphylococci  from  the  stools  of  every  infant  which  he  examined 
between  the  thirty-second  and  the  ninety-sixth  hour  after  birth. 
He  found  that  the  sooner  the  staphylococci  appeared,  the  sooner  the 
stools  took  on  a  dyspeptic  character,  and  when  the  intestinal 
symptoms  were  at  their  height,  these  organisms  dominated  the 
bacterial  flora.  He  believes  that  every  infant  has  a  staphylococcus 
enteritis  in  the  first  days  of  life.  The  etiological  significance  of 
these  cocci  is,  however,  questionable. 

Von  Reuss2  states  that  he  has  not  infrequently  seen,  usually 
toward  the  end  of  the  first  week  of  life,  even  temporarily,  muco- 
hemorrhagic  stools,  dysenteric  in  character,  which  did  not,  however, 
impair  the  general  health.  He  also  states  that  the  entrance  of 
staphylococci  into  the  oral  cavity  of  the  infant  and  from  there 
into  the  intestine  cannot  be  avoided,  even  with  the  most  extreme 
care  on  the  part  of  the  attendants,  because  the  cocci  may  come  from 
the  milk  ducts  or  the  genital  canal  of  the  mother.  While  the 
milder  types  of  enteritis  are  brought  about  by  the  irritation  of  the 
bacteria  or  their  products  of  decomposition  of  the  normal  intestinal 
content,  they  are  distinguished  with  difficulty  clinically  from  the 
forms  of  enteritis  which  are  caused  by  pathogenic  microorgani-m-. 

Although  in  most  instances  the  important  element  of  time  and 
lack  of  laboratory  facilities  precludes  the  making  of  a  diagnosis  ;i- 
to  the  specific  causative  organism,  in  the  light  of  the  more  modern 
work  of  Passini3  in  his  studies  of  the  new  born,  and  Kendall  and 
Day4  and  others  in  older  infants,  the  results  of  their  studies  are 
equally  applicable  to  infections  in  the  premature.  Passini  found 
that  with  the  introduction  of  human  milk  into  the  lower  part  of 
the  intestinal  tract  the  meconial  flora  consisting  largely  of  the 

1  Monatschr.  f.  Geb.  u.  Gyniik.,  1900,  24,  29. 

2  Die  Krankheiten  des  Neugeborenen,  Berlin,  1914. 

3  A  Study  of  the  Anaerobic  Intestinal  Bacteria,  Jahrb.  f.  Kinderh.,  1911,  73,  1011. 

4  Boston  Med.  and  Surg.  Jour.,  1913,  169,  753. 


284  DISEASES  OF  THE  GASTRO-lNTESTlNAL  TRACT 

speculating  forms  of  the  gas  bacillus  were  changed  to  the  fermenta- 
tive, aerogenous  forms,  which  were  capable  of  forming  irritative 
products  which  frequently  resulted  in  an  increase  of  stools  more 
or  less  foamy,  containing  increased  quantities  of  mucus.  These 
stools  are  frequently  seen  during  the  first  days  of  nursing  and  are 
the  so-called  "  transitional  stools."  However,  these  products  of 
food  decomposition  may  reach  a  considerable  degree  of  intensity 
and  be  associated  with  morbid  manifestations  (von  Reuss). 

Having  thus  described  the  mild  types  of  irritation  of  the  first 
group  due  to  the  ingestion  of  staphylococci  and  of  the  second  group 
due  to  the  transformation  of  the  gas-forming  flora  of  the  meconium 
into  the  aerogenous  organisms,  as  seen  after  the  ingestion  of  milk, 
with  the  resultant  irritation  due  to  the  fermentative  action  on  the 
milk  sugar,  we  come  to  the  large  class  of  cases  which  may  be  due 
to  one  of  many  types  of  organisms.  Those  due  to  streptococcus 
infections  through  the  maternal  circulation  before  birth  (which  in 
itself  may  be  the  cause  of  premature  birth),  or  the  secondary 
infections  through  the  mother's  milk,  lochia  or  other  products 
entering  the  gastro-intestinal  tract  by  way  of  the  mouth,  are 
among  the  most  virulent. 

The  Streptococcus  enteritis  may,  therefore,  make  its  appearance 
very  early  in  life  depending  upon  the  time  of  infection.  In  prema- 
ture infants  it  has  a  very  high  mortality.  The  various  bacillary 
infections  of  the  intestinal  tract  due  to  the  colon  bacillus,  dysentery 
bacillus,  typhoid,  paratyphoid  bacillus,  etc.,  with  the  exception  of 
the  colon  bacillus,  are  rarely  seen  during  the  first  days  of  life, 
unless  the  mother  is  suffering  with  an  infection  due  to  one  or  the 
other  organism.  The  clinical  symptoms  are  dependent  upon  the 
fetal  age  and  stage  of  development  of  the  individual  infant  and  upon 
the  type  and  virulence  of  the  infecting  organism.  The  general 
health  of  the  infant  suffers  in  all  cases.  Weight  has  a  tendency 
to  become  stationary  or  show  a  loss.  The  temperature  curve  varies 
directly  with  the  influencing  factors  and  the  reaction  on  the  part 
of  the  infant,  in  the  milder  types  being  dependent  to  a  great  degree 
on  the  absorption  of  the  toxic  products.  Vomiting  is  an  almost 
constant  factor,  and  the  stools  which  are  at  first  frequent,  con- 
taining food  material  when  developing  after  the  first  few  days 
of  life,  or  meconium  if  the  infection  be  very  early,  show  mucus  and 
often  gas,  depending  upon  the  infecting  organism,  and  in  the  severe 
cases  sooner  or  later  blood.  Even  the  premature  infant  will  give 
evidence  of  pain  and  tenesmus  as  seen  by  its  facial  distortion,  its 
low  whining  cry,  and  drawing-up  of  the  lower  extremities.  In  the 
great  majority  of  cases  the  abdomen  is  sunken  rather  than  dis- 
tended. The  skin  soon  becomes  dry.  The  body  fat  is  burned  up 
and  collapse  becomes  imminent.     The  prognosis  is  in  each  case 


DISEASES  OF  THE  GASTRO-IXTESTIXAL  TRACT         285 

dependent  upon  the  exciting  factors,  the  degree  of  resistance,  bul 
in  all  cases,  however  mild,  the  outcome  remains- in  doubt. 

Treatment.— The  therapy  of  these  cases  offers  one  of  the  mosl 

difficult  problems  confronting  the  pediatrician,  because  of  the 
danger  of  marasmus  following  even  short  periods  of  starvation, 
and  because  of  the  limitations  of  dietetic  treatment.  Human  milk 
is  indeed  the  only  food  which  can  be  given  with  any  degree  of 
safety,  and  this  at  the  same  time  because  of  its  high  sugar  content 
offers  a  splendid  culture  medium  for  the  gas-forming  organism. 
The  frequent,  somewhat  foamy,  mucous  stools  which  are  seen 
during  the  transitional  period,  that  is,  in  the  change  from  the 
meconial  stools  to  the  normal  breast-fed  stools  as  well  as  the  fre- 
quent stools  of  similar  formation  as  seen  after  this  period,  when 
unassociated  with  temperature,  loss  in  weight,  and  other  symptoms 
indicative  of  serious  trouble,  should  not  lead  to  dietetic  changes, 
but  breast  nursing  should  be  continued  as  long  as  there  is  an  absence 
of  all  signs  of  beginning  general  disturbance.  When  the  infant 
is  feeding  on  the  milk  of  its  mother  similar  but  physiological  stools 
are  very  commonly  seen  during  the  period  in  which  she  is  secreting 
colostrum  and  are  not  to  be  confused  with  intestinal  infection. 
Evidence  of  more  serious  infection  should  lead  to  a  short  period 
of  feeding  on  inert  fluids  of  proper  volume.  This  period  of  starva- 
tion in  most  eases  should  not  be  continued  over  six,  or  at  the  most, 
twelve  hours,  and  should  be  followed  by  gradual  feeding  of  smaller 
quantities  of  human  milk  than  has  been  previously  given.  Where 
there  is  question  as  to  the  mother's  milk  being  the  source  of  infec- 
tion, wherever  possible,  the  milk  should  be  obtained  from  another 
source,  or  the  mother's  milk  should  be  sterilized  before  feeding. 
This  latter  is  easily  accomplished  because  in  most  cases  premature 
infants  are  hand-fed  during  the  first  few  days  of  life.  These 
measures  should  be  carried  out  until  bacteriological  examination 
is  completed. 

The  intestinal  tract  may  be  cleansed  by  the  administration  of  a 
single  dose  of  castor  oil,  varying  from  10  to  30  minims,  depending 
upon  the  age  of  the  infant  and  the  conditions  at  hand.  The  large 
bowel  may  be  emptied  by  irrigations  of  normal  saline  solution, 
which  later  may  also  be  given  as  small  repeated  nutritive  enema ta 
after  the  intestinal  tract  is  once  thoroughly  cleansed.  Vomiting 
may  be  allayed  by  very  careful  gastric  lavage,  small  quantities  of 
saline  solution  being  left  in  the  stomach  after  the  washing.  Lavage 
must  be  rapidly  and  dexterously  performed  to  avoid  attack-  of 
cyanosis.  Brandy  (1  to  5  minims),  or  aromatic  spirits  of  ammonia 
(1  to  2  minims),  at  regular  intervals  are  the  best  forms  of  stimula- 
tion for  oral  administration.  Minimum  doses  of  paregoric  (|  to  2 
minims)  will  frequently  allay  the  intestinal  peristalsis  and  relieve 


286  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

tenesmus,  both  of  which  add  to  the  dangers  of  the  intestinal  infec- 
tion. Intestinal  antiseptics  are  to  be  avoided.  Hypodermic 
stimulation  must  be  very  carefully  given  because  of  the  dangers 
of  toxic  effects  and  of  local  irritation.  Small  doses  of  camphor  in 
oil  (1  to  5  minims)  are  the  best.  In  the  artificially  fed  infant 
every  effort  should  be  made  to  obtain  human  milk. 

DISEASES  OF  THE  LIVER  AND  BILE  PASSAGES. 

Icterus  Neonatorum.— Two  varieties  must  be  distinguished — 
icterus  simplex  and  icterus  gravis. 

While  the  simple  form  of  icterus  is,  as  a  rule,  a  very  benign 
condition  usually  running  its  course  without  severe  systemic 
manifestations,  the  grave  type  is  especially  fatal  in  premature 
infants  in  whom  it  is  usually  a  clinical  manifestation  of  sepsis, 
syphilis,  hemorrhagic  diathesis,  or  some  grave  form  of  liver  insuffi- 
ciency or  bile-passage  obstruction. 

Frequency.— The  incidence  of  icterus  neonatorum  in  premature 
infants  varies  with  the  observer  from  15  to  100  per  cent.  This 
variation  probably  depends  upon  what  the  individual  observer 
considers  to  be  jaundice.  If  a  yellowish  tinge  to  the  nose  and 
cheeks  is  regarded  as  sufficient  to  make  the  diagnosis  then  the 
percentage  will  be  high;  should  staining  of  the  conjunctiva?  only 
be  taken  as  evidence  the  number  will  be  low.  The  term  "true 
icterus"  can  be  applied  only  to  those  cases  in  which  the  yellow 
discoloration  of  the  skin  is  caused  by  a  staining  of  the  bile  pigments. 

Pathology.— Autopsy  in  moderate  cases  shows  that  the  intima 
of  the  arteries,  the  serous  membranes  and  the  various  body  fluids  and 
the  interstitial  tissues  are  stained  yellow,  but  the  brain,  the  cord, 
liver,  spleen  and  kidneys  are  usually  only  slightly  stained,  if  at 
all.  In  severe  types,  however,  deposition  of  bilirubin  crystals 
may  be  found  in  the  cells  of  the  skin,  in  the  capillaries  and  lym- 
phatics and  also  in  the  renal  pyramids,  blood,  adipose  tissues, 
brain  and  other  organs. 

Etiology.— The  recent  work  of  A.  Ylppo  offers  the  most  plausible 
solution  for  the  occurrence  of  jaundice  in  the  new  born,  and  his 
experiments  are  well  worth  quoting  in  detail.  His  experiments 
were  conducted  through  spectroscopic  analysis  of  the  blood  for  its 
bilirubin  and  biliverdin  content.  He  found  that  biliary  pigment 
secretion  is  small  until  the  late  fetal  months  are  reached.  Shortly 
before  birth  the  secretion  is  rapidly  increased,  and  this  increase  is 
intensified  after  birth. 

This  biliary  pigment  content  of  the  blood  increases  up  to  the 
third  to  the  tenth  day  and  on  the  whole  continues  for  a  longer  time 
in  the  premature  than  in  the  full  term,     He  found  that  blood 


DISEASES  OF  THE  LIVER  AND  BILE  PASSAGES         _'s7 

from  the  umbilical  vessels  averaged  from  13,0  58,2'10  '  per  LOO 
cc  of  blood  and  that  this  increased  from  the  third  to  the  tenth.  In 
those  cases  which  passed  12o,0-10_5  gm.  per  100  cc  of  blood,  icterus 
developed,  while  it  remained  absent  in  those  containing  less  than 
this  amount.  lie  also  found  that  there  was  a  direct  parallel  between 
the  blood  content  of  biliary  pigment  and  the  intensity  of  the  icterus: 
Clinical  manifestations  due  to  the  icterus  were  absent  in  the  mild 
cases,  while  in  the  severe  ones  the  cholemia  resulted  in  somnolence. 
He  found  little  evidence  that  syphilis,  sepsis  and  traumata  influem  e 
the  development  of  the  jaundice.  From  his  studies  he  concluded 
that  icterus  neonatorum  is  hepatogenous  in  origin  and  is  due  to 
the  fact  that  for  some  days  after  birth  the  liver  continues  to  secrete 
bile  into  the  blood  stream  by  the  same  routes  that  this  occurs  in 
fetal  life  and  that  due  to  the  fact  that  there  is  an  intensified  se<  re- 
turn of  bile  pigment  shortly  before  and  after  birth,  the  blood  content 
of  bile  is  increased,  and  that  these  findings  result  in  the  development 
of  the  icterus  when  in  excess.  He  therefore  believes  that  it  is  a 
physiological  process  which,  however,  may  become  pathological 
when  the  blood  content  becomes  excessive. 

The  earlier  explanation  of  Knopfelmacher  offers  a  closely  related 
explanation.  He  describes  two  factors  as  concerned  in  production 
of  jaundice  in  the  new  born,  a  hypersecretion  of  bile  and  a  dis- 
turbance of  excretion.  The  richness  of  the  blood  supply  to  the 
liver  immediately  after  birth  is  responsible  for  a  greatly  increased 
production  of  bile  at  this  time,  while  during  the  first  few  days  of 
life  there  is  only  a  rudimentary  functioning  secretory  mechanism. 
Accordingly  the  tenacious  and  stagnated  bile  passes  from  the 
overfilled  bile  capillaries  into  the  blood  capillaries. 

The  increased  viscosity  of  the  bile  during  the  first  days  of  life 
is  explained  by  Pacchioni  as  being  due  to  the  loss  of  water  sustained 
by  the  infant  at  this  time,  leading  to  a  greatly  slowed  biliary  current 
with  absorption  into  the  blood  and  lymph  stream. 

A  hematogenous  origin  of  the  bile  in  icterus  neonatorum  may  be 
excluded  by  the  experiments  of  Minkowski  and  Nyuyn,  who 
demonstrated  that  the  liver  is  essential  for  the  formation  of  bile 
and  that  without  this  organ  jaundice  cannot  be  induced.  The 
connection  of  icterus  with  a  stasis  of  bile,  the  result  of  the  closure 
of  the  ductus  choledochus  by  meconium  (Franck),  by  desquamated 
epithelium  (Cruse),  or  by  a  plug  of  mucus  (Virchow),  is  not  sup- 
ported by  the  facts;  neither  is  Birch-Hirschfeld's  theory  of  edema 
of  the  capsule  of  Glisson,  Bouchut's  theory  of  a  hepatitis,  or 
Epstein's  explanation  that  the  cause  is  a  catarrh  of  the  small  bile 
ducts. 

Freirichs  explained  the  jaundice  by  a  marked  anemia  and  decrease 
in  pressure  in  the  liver  capillaries,  which  in  turn  lead  to  a  lessened 


288  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

pressure  in  the  bile  capillaries  and  an  overflow  of  bile  into  the 
blood  stream.  The  great  degree  of  congestion  of  the  hepatic  capil- 
laries at  birth  precludes  this  belief,  however,  while  the  fact  that 
the  blood-pressure  is  raised  in  asphyxia  neonatorum,  in  which 
condition  icterus  is  especially  intense  also  nullifies  this  theory. 

Symptoms.  — In  very  mild  cases  the  yellow  color  may  appear 
only  on  the  face,  chest  and  back,  the  conjunctiva3  being  but  faintly 
tinted  and  the  urine  and  feces  normal  in  appearance.  In  severer 
forms  the  urine  may  be  high  colored  enough  to  stain  the  linen, 
and  the  jaundiced  hue  may  extend  to  the  arm  and  abdomen.  Some 
infants  present  a  yellowish  discoloration  of  the  whole  body,  with 
typical  clay-colored  stools.  In  most  cases  the  jaundice  has  dis- 
appeared by  the  eighth  or  tenth  day.  It  may  persist  for  several 
weeks.  In  rare  cases,  after  having  much  diminished,  it  reappears 
with  renewed  intensity.  The  liver  and  spleen  are  usually 
unchanged,  however;  in  the  severer  types  liver  changes  are  the 
rule  and  it  is  usually  found  enlarged. 

An  early  type  often  seen  from  six  to  twelve  hours  after  birth 
is  not  infrequent  in  small  prematures.  These  are  usually  severe 
cases  and  although  not  of  the  septic  type  are  slow  in  disappearing. 

While  most  of  the  simple  cases  are  unassociated  with  gastro- 
intestinal and  febrile  disturbances  the  severer  types  even  of  the 
simple  form  are  associated  with  symptoms  of  indigestion  which  is 
always  of  grave  import  in  the  premature.  They  are  also  subject 
to  febrile  disturbances  and  are  slow  in  overcoming  their  initial 
weight  losses. 

Diagnosis.  — Icterus  neonatorum  being  a  physiological  condition, 
it  must  be  differentiated  from  jaundice  due  to  causes  other  than  a 
mere  disturbance  of  interrelation  between  formation  and  excretion. 
There  must  be  excluded  septic,  syphilitic  and  familial  jaundice, 
that  due  to  deformities  or  obliteration  of  the  biliary  passages,  and 
three  or  four  rarer  conditions  characterized  by  icterus. 

Septic  Jaundice. — Gessner  believes  that  many  instances  of 
so-called  benign  icterus  neonatorum  are  dependent  upon  umbilical 
infection,  and  DeLee  agrees  with  him.  Other  cases  are  thought 
to  be  due  to  intestinal  infection. 

In  these  cases  the  child  is  ill,  the  temperature  is  elevated  and 
the  skin  shows  a  marked  degree  of  icterus,  which  in  the  severer 
cases  becomes  a  bronzing.  Hemorrhages  are  often  present,  some- 
times a  foul-smelling  pus  exudes  from  the  umbilicus,  there  is  ano- 
rexia and  the  abdomen  may  be  distended  and  tender.  Blood 
cultures  sometimes  reveal  the  causative  organisms  or  they  can 
be  demonstrated  in  the  septic  foci.  The  outlook  for  these  children 
is  poor,  the  younger  and  less  mature  the  infant,  the  less  is  its  chance 
of  recoverv. 


DISEASES  OF  THE  LIVER  AND  BILE  PASSAGES  289 

Syphilitic  Jaundice.  -This  form  of  jaundice  is  usually  present  at 
birth  or  appears  a  few  days  later.  It  is  generally  rather  intense 
and  may  persist,  though  sometimes  it  improves,  only  to  recur  again. 
Hemorrhages  under  the  skin  are  not  at  all  uncommon.  It  should 
be  suspected  if  other  signs  of  syphilis  are  present,  especially  a 
positive  Wassermann  reaction. 

Family  Acholuric  Jaundice  —  This  is  a  chronic  condition  charac- 
terized by  jaundice  of  long  duration,  the  presence  of  bile  pigments 
in  the  stools  and  their  absence  in  the  urine.  The  spleen  is  usually 
but  not  always  enlarged,  there  is,  as  a  rule,  more  or  less  anemia 
present  and  some  enlargement  of  the  liver.  The  affection  is  com- 
patible with  life  but  occasionally  there  occur  slight  rises  in  tem- 
perature with  malaise,  diarrhea,  abdominal  pain  and  an  increase 
in  icterus.  This  jaundice  has  been  explained  on  the  basis  of  a 
simple  cholemia,  biliary  cirrhosis,  splenomegalic  jaundice,  or  it 
may  be  that  all  the  conditions  are  but  different  stages  of  the  same 
affection. 

Prognosis.  — It  must  be  kept  in  mind  that  icterus  neonatorum 
may  he  of  prolonged  duration  and  yet  be  only  due  to  disturbance  of 
bile  secretion  and  excretion,  and  not  dependent  on  malformation, 
sepsis  or  other  disease.  An  increase  in  the  intensity  of  the  icterus 
during  the  second  week  should  make  one  suspicious  of  some  causa- 
tive condition  more  serious  than  that  responsible  for  a  simple 
icterus  neonatorum. 

Treatment.— There  is  no  treatment  for  simple  icterus  of  the  new 
born,  nor  is  any  needed  though  small  doses  of  calomel  with  sodium 
bicarbonate  and  sodium  phosphate  have  been  recommended. 

Affections  of  the  Excretory  Bile  Ducts.  — (a)  Stenoses  and  Atre- 
sias.—The  common,  hepatic  or  cystic  ducts,  one  or  all,  may  he 
affected  in  congenital  stenoses.  The  more  common  etiological 
factors  are  as  follows:  (1)  One  or  more  of  the  ducts  and  even  the 
gall-bladder  may  be  totally  absent;  (2)  fetal  inflammatory  pro- 
cesses of  obscure  origin  may  result  in  atresias;  (3)  pathological 
development  at  the  distal  end  of  the  common  duct  with  a  valve- 
like formation  may  result  in  atresia  (similar  formations  may  be 
present  in  the  mucous  membrane  at  other  locations  in  the  bile 
passages);  (4)  hereditary  syphilis  may  result  in  a  perihepatitis,  or 
cholangitis;  and  (5)  occlusion  may  be  due  to  inspissated  bile  or 
concretions. 

Symptoms.—  Acholic  stools  are  present  where  there  is  an  involve- 
ment of  the  hepatic  or  common  duct  or  both.  This  may  or  may 
not  be  evident  in  the  meconium  depending  upon  the  causative 
factor.  Progressive  icterus  is  an  almost  constant  finding.  I  rinary 
findings  correspond  to  the  degree  of  stenosis,  and  there  is  undigested 
fat  in  the  stools  when  fat  is  contained  in  the  infant's  food. 
19 


290  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

Prognosis.— Death  soon  follows  in  the  cases  where  the  stenosis 
is  the  cause  of  premature  birth.  However,  in  other  cases  where 
it  is  simply  a  part  of  the  general  picture  of  congenital  lues,  or 
occlusion  is  less  complete,  the  infants  may  survive  for  a  consid- 
erable time,  depending  upon  the  degree  of  systemic  involvement. 
Death  is  usually  due  to  intercurrent  infection,  which  is  not  uncom- 
monly through  the  gastro-intestinal  tract,  or  inanition  due  to  lack 
of  fat  digestion  or  to  cholemia.  All  cases  of  complete  occlusion 
are  fatal  in  the  premature. 

Treatment.— In  all  cases  except  those  due  to  inspissated  bile 
and  lues  the  treatment  would  be  surgical,  but  such  interference 
is  practically  hopeless  in  this  class  of  cases  and  is  rarely  to  be 
advised  in  premature  infants.  The  medical  treatment  of  congenital 
syphilis  is  far  from  hopeless.  A  much  poorer  prognosis  is  offered 
in  stenosis  of  the  ducts  than  in  those  cases  where  jaundice  is  due 
to  a  hepatitis. 

(6)  Gall  Stones.— Cholelithiasis  due  to  fetal  inflammatory  pro- 
cesses has  been  described  by  Bland-Sutton1  and  Cautley  states 
that  they  are  more  frequent  during  the  fetal  age  and  early  infancy 
than  at  any  other  period  of  childhood. 

(c)  Inflammations  of  the  Bile  Passages.— Although  they  are  rare 
they  may  be  due  to  ascending  infection,  but  are  more  commonly 
subacute  conditions  as  seen  in  congenital  syphilis. 

Affections  of  the  Hepatic  Vessels.— Phlebitis  and  thrombosis 
of  the  portal  vein  may  result  from  an  ascending  infection  through 
the  umbilical  vessels. 

Congenital  lues  may  be  associated  with  a  periphlebitis  of  the 
portal  vein,  or  its  intrahepatic  branches,  or  gummatous  infiltration 
about  the  hepatic  vessels.  When  the  portal  vein  is  the  seat  of  con- 
siderable obstruction,  ascites,  gastric  and  intestinal  hemorrhages, 
enlargement  of  the  liver  and  splenic  tumor  usually  result. 

•     BIBLIOGRAPHY  OF  ICTERUS  NEONATORUM. 

Minkowski-Nyuyn :     Arch.  f.  exper.  Pathologie,  21,  1. 

Franck,  J.  Peter:     De  curandis  hominum  morbis  Epitome,  1805,  55,  183. 

Cruse,  P.:     Arch.  f.  Kinderheilk.,  1,  353. 

Virchow,  R.:     Gesammelte  Abhandlungen,  s.  847. 

Birch-Hirschfeld,  F.  V.:     Virchow's  Arch.,  1882,  87,  1. 

Bouchut  (quoted  from  Marcel  Delestre) :  Etude  sur  les  infections  chez  le  pre- 
mature, Paris,   1901. 

Epstein:     Volkmann's  Sammlung  klin.  Vortrage,  1880,  Nr.  180. 

Freirichs:     Klin.  d.  Leberkrankh.,  1858,  p.  1. 

Quincke:  Arch.  f.  exper.  Pathol,  u.  Pharmakol.,  1885,  19,34;  Virchow's  Arch., 
1884,  p.  95. 

Meckel,  H.:     Charite-Annalen,  alte  Folge  4,  1853. 

DeLee:     Principles  and  Practice  of  Obstetrics,  Philadelphia,  1913. 

1  Gall  Stones  and  Diseases  of  the  Bile  Ducts,  1911. 


DISEASES  OF  THE  LIVER  AND  BILE  PASSAGES         291 

Knopfelmacher,  W.:     Jahrb.  f.  Kinderhoilk.,  1898,  p.  47;     1908,  p.  67. 
Hess,  A.  F.:     Am.  Jour.  Dis.  Child.,   1912,  p.  :304. 
Abramow,  S.:     Virchow's  Arch.,  181,  201. 
Pacchioni:     Rivista  di  clinica  pediatr.,  1911,  9,  333. 
Ylppo,  A.:     Ztschr.  f.  Kinderheilk.,   1913,  9,  208. 

Affections  of  the  Hepatic  Parenchyma.  -Although  the  liver  is 
readily  influenced  by  toxic  and  infectious  products,  which  easily 
pass  through  the  permeable  gastro-intestinal  wall,  nevertheless,  it 

is  exceedingly  difficult  to  recognize  the  part  which  this  great  organ 
plays. 

Among  the  most  common  affections  of  the  liver  is  the  predis- 
position to  icterus,  which  appears  especially  early  in  prematures. 
Besides  the  physiological  jaundice,  icterus  may  accompany  a 
variety  of  disorders.  In  the  later  life  we  see  different  types  of 
icterus,  aside  from  obstruction  of  the  gall  ducts,  as:  Septic 
icterus,  Winckel's  disease,  catarrhal  icterus,  toxic  jaundice  and 
acute  atrophy. 

Parenchymatous  and  fatty  degeneration  of  the  liver  is  present 
in  all  septic  diseases.  Degenerative  liver  processes  are,  however, 
seen  where  there  is  no  focus  of  infection  and  these  are  probably  due 
to  toxins,  which  are  absorbed  from  the  placenta,  as  in  the  cases 
of  infants  born  of  eclamptic  mothers,  perishing  shortly  after  birth. 
In  some  such  instances  there  may  be  no  gross  change  but  micro- 
scopically a  high-grade  degeneration  exists.  In  addition,  as 
previously  mentioned,  subcapsular  liver  hemorrhages  occur  quite 
frequently.  Ylppo1  was  able  to  demonstrate  such  lesions  in  almost 
80  per  cent  of  the  prematures  under  1000  gm.  birth  weight,  and 
only  in  5  per  cent  of  those  weighing  between  2000  to  2.100  gm.  At 
times  the  hemorrhages  may  be  very  extensive  and  with  rupture 
of  the  liver  capsule  result  fatally.  Parenchymatous  liver  hemor- 
rhages may  also  be  found,  but  they  are  small  and  are  not  of  much 
significance. 

In  the  literature  one  finds  mention  of  cases  of  acute  yellow 
atrophy  of  the  liver  with  the  finding  of  tyrosin  and  leucin  in  the 
urine,  coagulation  necrosis  and  hemorrhages  into  the  parenchyma. 

Septic  icterus  is  characterized  by  a  marked  acute  interstitial 
and  parenchymatous  hepatitis.  In  some  cases  there  have  heen 
noted  cyanosis,  convulsions  and  digestive  disturbances,  which 
either  disappeared  in  a  few  days  or  led  to  death.  In  these  i  ases 
the  liver  symptoms  are  cloaked  by  those  of  general  sepsis. 

Icterus  catarrhalis  is  often  associated  with  duodenal  catarrh 
and  cholangitis,  and  is  characterized  by  jaundice,  acholic  stools, 
bilirubinuria,  and  the  prognosis  is  on  the  whole  good. 

1  Pathologisch-anatomische  Studien  bei  Fruhgeburten,  Ztschr.  f.  Kinderh.,  L919, 
20,  329. 


292  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

Cirrhotic  processes  in  the  liver  are  usually  associated  with  con- 
genital syphilis  or  deformities  of  the  gall  tracts.  One  sees  a  diffuse 
interstitial  luetic  hepatitis  under  the  picture  of  hypertrophic 
cirrhosis.  With  anomalies  of  the  gall  ducts  there  is  a  biliary 
cirrhosis. 

Congenital  Tumors  of  the  Liver.  —These  in  themselves  may  be 
the  cause  of  premature  birth.  However,  most  of  the  cases  of 
malignant  tumors  described  in  the  literature  are  those  which  have 
developed  after  birth  in  infants  either  born  in  seeming  health  at 
full-term,  or  those  congenitally  debilitated,  but  who  did  not  give 
evidence  of  tumor  formation  until  some  time  after  birth;  while 
the  cases  giving  evidence  of  tumor  formation  at  birth  have  been 
commonly  angiomata  or  cystic  degenerations. 

DISEASES  OF  THE  PERITONEUM. 

Fetal  Peritonitis.— Intra-uterine  peritonitis  is  usually  chronic  in 
character,  and  in  premature  infants  usually  results  in  death  shortly 
after  birth,  if  not  already  the  cause  of  still  birth. 

Etiology  and  Pathogenesis.  — 1.  Malformations  in  the  digestive 
tract  with  emptying  of  the  contents  into  the  peritoneal  cavity. 
It  is  also  quite  possible  that  some  of  the  malformations  described 
previously  may  result  from  secondary  changes  due  to  fetal  peri- 
tonitis. 

2.  Malformations  of  the  genito-urinary  tract  may  likewise 
cause  fetal  peritonitis  owing  to  the  extravasation  of  urine  into  the 
abdominal  cavity. 

3.  Spontaneous  rupture  of  any  of  the  hollow  abdominal  viscera 
with  extravasation  of  their  contents  may  result  in  peritonitis. 

4.  Congenital  syphilis  is  frequently  associated  with  fetal  perito- 
nitis (Simpson.1)  Maceration  of  the  peritoneum,  as  frequently 
seen  in  still  births  in  congenital  lues,  should  not  be  mistaken  for 
true  peritonitis. 

5.  True  congenital  tuberculosis  may  be  a  causative  factor  and 
Mya2  believes  that  the  toxic  bodies  circulating  in  the  blood  of  a 
tuberculous  mother  may  in  themselves  cause  peritonitis  without 
the  presence  of  the  specific  organisms. 

6.  Various  septic  infections  may  pass  through  the  placental 
circulation  into  the  fetal  body  and  may  among  other  lesions  cause 
peritonitis. 

Symptoms.— The  symptoms  depend  upon  the  degree  of  peritoneal 
involvement  and  the  nature  of  the  cause.  In  living  infants  where 
the  process  is  localized,  there  may  be  but  few  symptoms  at  birth, 

1  Cases  of  Intra-uterine  Peritonitis,  Zentralbl.  f.  Gynak.,  1S77,  p.  4S. 

2  Monatsscbrift  f.  Kinderh.,  1906,  4,  341. 


HERNIA  293 

l>ut  such  a  process  usually  results  in  the  formation  of  adhesions 
and  the  development  of  intestinal  obstruction  in  surviving  infants. 
More  commonly  the  process  is  generalized,  the  abdomen  distended, 
containing  more  or  less  effusion  with  resulting  dyspnea  and  cyanosis 

and  the  early  development  of  ileus. 

Prognosis.  — Premature  infants  with  fetal  peritonitis  rarely  sur- 
vive the  first  days  of  life  and  even  the  cases  of  localized  peritonitis 
usually  result  in  early  death  because  of  the  inability  of  the  individual 
to  withstand  surgical  interference. 

Acute  Peritonitis.— Etiology.— It  rarely  occurs  as  a  localized 
affection  in  the  premature.  The  most  common  sources  of  infection 
are: 

1.  Hematogenous,  either  through  general  sepsis  or  local  infection 
in  some  distant  part. 

2.  Infections  through  the  umbilical  cord. 

3.  Infections  through  the  intestinal  canal  either  through  rupture 
of  the  intestines  due  to  trauma  (this  is  usually  located  in  the  region 
of  the  sigmoid  flexure),  or  the  passage  of  bacteria  into  the  peritoneal 
cavity,  either  through  the  uninjured  intestinal  wall,  or  through  the 
inflamed,  ulcerated  or  gangrenous  bowel  wall. 

Symptoms.— Violent  vomiting,  abdominal  distention  with  either 
diarrhea  or  obstipation,  usually  temperature,  although  it  may  remain 
subnormal,  rapid  respirations  and  pulse,  not  infrequently  marked 
icterus,  and  early  collapse  are  the  usual  findings.  The  diagnosis 
is  often  impossible  before  death  owing  to  the  rapid  development 
of  similar  findings  in  the  premature  from  other  causes,  unless 
there  is  evidence  of  transmission  from  some  localized  source  of 
infection,  as  about  the  umbilicus. 

Prognosis. — Entirely  unfavorable. 

HERNIA. 

Congenital  Diaphragmatic  Herniae. —These  hernias  are  described 
as  true  and  false.  The  true  diaphragmatic  hernias  are  covered 
by  the  peritoneum  and  there  is  no  direct  communication  between 
the  pleural  and  the  abdominal  cavities.  In  the  latter  or  false 
type  there  is  really  an  extrusion  of  the  abdominal  organ,  and 
therefore  a  direct  communication  between  the  abdominal  and 
pleural  cavities.  The  latter  are  by  far  the  more  frequent  type 
and  the  left  side  is  more  commonly  involved  than  the  right.  The 
diagnosis  offers  considerable  difficulty  in  the  premature  and  because 
of  the  commonly  associated  cyanosis  they  are  usually  diagnosed 
as  congenital  atelectasis,  a  diagnosis  which  is  not  greatly  in  error 
as  the  lung  on  the  side  involved  is  not  infrequently  entirely  undevel- 
oped. In  contradistinction  to  full-term  infants  who  may  live  to 
considerable  age,  premature  infants  usually  succumb  during  the 


294  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

first  hours  or  days  of  life  with  symptoms  of  asphyxia  and  cyanosis, 
usually  due  to  gastric  or  intestinal  distention  within  the  chest 
cavity  (Figs.  154  and  155,  pages  256  and  257). 

Ventral  (Lateral)  and  Lumbar  Herniae.— Etiology.— They  are 
usually  due  to  defects  or  arrested  development  of  the  lateral 
abdominal  or  lumbar  muscles.  They  may,  however,  result  from 
increased  intra-abdominal  pressure. 

Prognosis.— This  depends  on  the  extent  of  the  hernia  and  the 
general  development  of  the  infant.  Three  cases  which  I  have 
seen  in  premature  infants  who  survived  resulted  in  spontaneous 
recovery. 

Treatment.— During  the  first  months  of  life  treatment  must 
necessarily  be  limited  to  abdominal  bandages  or  adhesive  strips. 

Umbilical  and  Inguinal  Herniae.— Navel  and  inguinal  hernise  are 
especially  common  in  the  premature.  Ylppo1  found  hernia?  of  one 
or  both  varieties  in  84  per  cent  of  the  premature  infants  with  a 
birth  weight  of  less  than  1500  gin.  before  the  third  month. 

Umbilical  and  Inguinal  Hernle  (Ylppo). 

Weight  in  grams.  No.  of  Hernia  Per 

cases.  present.  cent. 

1000  1  1 

1001  to  1500 50         42         84.0 

1500  to  2000 81         31         38.3 

2000  to  2500 73         15         20.5 

Inguinal  her  nice  are  rarely  observed  at  birth,  usually  developing 
when  the  infant  is  several  days  or  weeks  old,  following  intra- 
abdominal distention  or  severe  crying  in  stronger  infants.  They 
are  most  frequently  bilateral  and  are  fairly  common.  The  testicles 
are  often  undescended,  leaving  a  direct  communication  with  the 
abdominal  cavity  which  is  followed  by  rupture  of  the  processus 
vaginalis  communis  through  the  canal.  This  is  rather  interesting 
when  we  note  that  the  processus  vaginalis  is  open  at  birth  in  the 
majority  of  infants  prematurely  born.  The  tendency  to  meteorism, 
which  so  commonly  exists,  enhances  the  development  of  hernias 
under  these  conditions.  While  incarceration  is  rare,  and  reduction 
usually  easy  due  to  the  elastic  walls,  strangulation  does  occasion- 
ally occur  and  is  always  dangerous  if  neglected. 

Treatment.— Operative  interference  is  usually  out  of  the  question, 
and  we  of  necessity  have  recourse  to  conservative  treatment.  Steel 
trusses  almost  invariably  cause  trauma  and  erosion,  with  the 
dangers  of  infection  which  are  of  graver  importance  than  the 
dangers  of  strangulation  due  to  the  hernia.  Conservative  treat- 
ment by  the  use  of  yarn  trusses  as  first  devised  by  Fiedler2  or  by 

1  Ztschrft.  f.  Kinderh.,  1919,  24,  1. 

2  Zentralbl.  f.  Chir.,  1906,  33,  1161.     Deutsch.  med.  Wchnschr.,  1907,  p.  105. 


HERNIA  295 

the  simple  truss  designed  by  Dr.  Andrew  A.  (lour  oilers  the  simplest 
and  best  methods  of  treatment,  and  in  the  majority  of  cases  results 
in  spontaneous  eure  (Fig.  157). 


Fig.  156. — Illustrating  the  application  in  inguinal  hernia.  A  pure  wool,  white 
yarn  -i-ply  is  wound  into  a  skein  of  fifteen  to  twenty  strands,  from  15  to  20  inches 
in  length,  depending  upon  the  size  of  the  infant  to  which  it  is  to  be  applied.  To 
prevent  tangling  it  is  knotted  by  a  single  strand  at  six  points.  A  single  loop  is 
made  which  is  passed  around  the  body  at  the  level  of  the  crests  of  the  iliac  bones, 
with  loop  coming  directly  over  the  hernia.  Fixing  the  loop  at  this  point  with  the 
finger,  the  free  end  is  now  passed  from  above  downward  between  the  strands,  mak- 
ing a  snug  knot  which  is  fixed  over  the  hernia.  The  free  end  is  then  passed  between 
the  thighs  where  it  is  fastened  to  the  main  loop  over  the  back  by  tying  with  tape 
or  by  the  use  of  a  narrow  rubber  elastic  to  which  snap  fasteners  are  sewed.  They  are 
made  to  meet  the  needs  of  each  individual  case.  Such  a  truss  should  be  worn  for 
two  or  three  months  or  longer.  The  strand  passing  between  the  legs  can  be  protected 
from  excreta?  by  a  cigarette  made  from  oiled  silk  which  can  be  slipped  over  the  free 
end  before  fastening.  Six  skeins  should  be  kept  on  hand.  They  can  be  washed 
in  gasoline  and  soap  and  water.     They  should  be  stretched  while  drying. 

The  average  mother  or  nurse  can  easily  be  taught  to  make  the 
bandage  from  a  good  quality  of  poplin  and  of  such  size  as  will 


296 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 


meet  the  infant's  needs.  It  is  usually  necessary  for  the  infant 
to  wear  the  above  improvised  truss  over  a  period  of  from  one  to 
three  months. 


Fig.  157. — Inguinal  hernia  bandage  with  small  oval  metal  pad  inserted  on  left  side. 

(Dr.  A.  Gour.) 


Fig.  158. — Pad  designed  by  author  for  use  with  hernia  bandage.  An  elliptical 
piece  of  fine  pore  rubber  sponge  is  glued  to  a  slightly  larger  piece  of  sole  leather. 
The  leather  is  perforated  at  four  points  so  it  can  be  stitched  into  the  bandage.  The 
rubber  pad  insures  close  approximation  and  elasticity  to  the  bandage. 

Umbilical  herniee  are  usually  not  extreme,  most  commonly  devel- 
oping during  the  first  month  increasing  up  to  the  third  month. 
With  proper  care  they  often  disappear  completely  by  the  end  of  the 
first  year  with  the  development  of  the  recti  and  the  other  abdominal 
wall  muscles. 

This  seems  to  be  hastened  when  the  child  reaches  the  age  of 


HERNIA 


297 


walking  where  the  cases  are  not  already  healed.  The  chief  factors 
in  the  causation  of  navel  hernia'  arc  the  weak  abdominal  walls,  the 
tendency  toward  rectus  diastasis  and  the  delayed  healing  and  falling 
off  of  the  cord,  which  averages  eight  to  ten  days  in  the  premature 
as  compared  with  five  to  seven  in  the  full  term.  The  diaphragmatic 
respirations  are  also  a  factor.  Although  we  may  have  hernia  of  the 
umbilical  cord  proper,  that  is,  true  congenital  umbilical  hernia,  the 
condition  more  commonly  described  as  navel  hernia  is  the  acquired 
hernia  of  the  umbilical  ring  due  to  deficient  closure,  resulting  in  the 
protrusion  of  the  omentum,  or  the  intestines  or  both  through  the 
ring  resulting  from  increased  intra-abdominal  pressure.  With 
proper  conservative  treatment  operative  interference  is  rarely 
necessarv. 


Fig.  159. — Umbilical  hernia  bandage;    j-inch  cotton  cigarette  and  strip  of  adhesive 

plaster. 

The  method  as  illustrated  usually  results  in  cure  in  from  one 
to  three  months,  and  if  a  good  grade  of  zinc  oxide  adhesive 
plaster  is  selected,  there  is  usually  little  excoriation  of  the  skin 
even  in  the  premature,  if  the  bandage  is  not  applied  until  the 
umbilical  wound  is  entirely  healed  and  all  granulation  tissue  has 
disappeared.  It  is,  therefore,  necessary  to  treat  the  umbilical 
wound  by  the  open  method  until  thoroughly  dried.  A  small 
"cigarette-like"  roll  is  made  of  cotton  about  h  inch  in  length  and 
from  |  to  I  inch  in  diameter,  depending  upon  the  size  of  the  hernia 
and  the  elasticity  of  the  abdominal  wall.  This  small  cotton  cigar- 
ette is  then  partially  or  entirely  buried  between  the  overlapping 


298 


DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 


skin  lateral  to  the  hernia,  and  while  it  is  being  held  by  the  operator 
(doctor,  nurse  or  mother)  a  strip  of  adhesive  plaster  about  3  inches  in 
length  and  If  inches  in  width  is  applied  directly  over  the  umbilicus. 


Fig.  160. — Umbilical  hernia  bandage.     Cotton  cigarette  in  place.     The  next  step 
consists  in  burying  the  cotton  by  folding  the  skin  over  it. 


Umbilical  hernia  bandage.     Adhesive  strap  in  place. 


We  have  found  the  short  strip  of  adhesive  plaster  preferable  to 
the  longer  strips  encircling  the  entire  body,  as  it  causes  less  irrita- 
tion, allows  greater  motor  activity  on  the  part  of  the  intestines, 
and  is  equally  efficient  in  the  treatment  of  these  cases. 


CHAPTER  XII. 

DISEASES  OF  THE  URINARY  TRACT. 

Smaller  or  larger  hemorrhages  in  the  kidney  capsule  are  frequent, 
but  extensive  extravasations  are  rare.  Minute  hemorrhages  oe 
the  renal  surfaces  are  common.  In  the  kidney  substance  hemor- 
rhages arc  most  commonly  found  at  the  apex  of  the  pyramids  and 

in  the  medulla.  Besides  this  zone  of  predilection  there  is  another 
at  the  junction  of  the  cortex  and  the  medulla.  Here  there  are  not 
always  hemorrhages  but  markedly  engorged  vessels  (vena?  et 
arteriae  arciformes).  Hemorrhages  occur  more  often  between  the 
urinary  tubules  than  in  them. 

Uric-acid  infarcts  are  found  as  yellowish  granules  in  the  kidney 
pyramids  of  prematures,  still-born  or  perishing  after  a  few  days 
of  life.  Hemorrhages  are  usually  present  also  in  the  same  regions. 
Bile  pigment  is  precipitated  in  the  kidney  in  the  same  areas  in 
which  there  is  the  predilection  for  hemorrhage. 

That  cylindruria  and  albuminuria  may  be  present  without  gross 
demonstrable  pathological  change  was  mentioned  before.  The 
transition  from  physiological  to  pathological  albuminuria  is  not 
abrupt  and  the  instance  of  severe  albuminuria  is  infrequent. 

Observations  have  been  so  few  in  the  cases  of  nephritis  in  newly 
born  prematures  that  an  exact  clinical  picture  has  not  been  e>tal>- 
lished.  Quite  frequently  one  finds  parenchymatous  or  fatty  degen- 
eration of  the  kidneys  following  toxic  or  infectious  conditions. 
Perhaps  the  most  outspoken  form  of  nephritis  in  the  new  born  is 
the  syphilitic.  An  interesting  question  is  the  influence  of  nephritis 
and  eclampsia  in  the  mother  on  the  kidneys  of  the  infant.  One 
commonly  sees  cases  where  the  infant  is  unaffected  and  the  urine 
retains  its  normal  character,  sometimes  even  when  the  premature 
shows  eclamptic  symptoms.  At  times  there  may  be  the  findings 
of  a  well-marked  hemorrhagic  nephritis  which  clears  up  within 
a  few  weeks.  Infrequently  the  infant  may  show  congenital  edema 
and  ascites.  The  presence  of  "hydrops  fetus  universalis"  has  been 
shown  to  have  some  relation  to  the  presence  of  nephritis  during 
pregnancy,  with  well-marked  renal  pathology,  causing  still  birth 
or  premature  birth  with  death  in  a  few  days. 

Shrunken  kidneys  have  been  demonstrated  in  the  infant  following 
chronic  nephritis  in  the  mother. 

A  relatively  large  portion  of  the  cases  of  nephritis  in  the  new 


300  DISEASES  OF  THE  URINARY  TRACT 

born  have  been  ascribed  to  infections  processes.  Thus  Mensi1 
examined  17  nephritic  infants,  ten  to  fourteen  days  old,  and  based 
the  condition  on  infections  secondary  to  the  diseases  of  the  respira- 
tory and  alimentary  tracts. 

ECLAMPSIA  NEONATORUM. 

The  analogue  of  classical  eclampsia  in  the  mother  is  very  seldom 
seen  in  newly  born  infants.  These  inay  show  no  untoward  symp- 
toms or  may  be  prematurely  born  dead,  or  if  alive  succumb  in  a 
few  days  from  degeneration  of  the  organs,  hemorrhages  or  nephritis. 
Convulsions  in  infants  born  of  eclamptic  mothers  are  quite  rare. 
Esch,2  in  1910,  was  able  to  collect  only  32  cases  from  the  literature 
and  his  own  experience.  The  convulsions  appear  in  the  first  days 
of  life,  sometimes  a  few  minutes  after  birth,  usually  before  the 
end  of  the  second  day.  Involvement  of  the  eye  muscles  is  usually 
first  noted,  then  cyanosis  appears,  followed  by  tonic  and  clonic 
spasms  of  the  body  musculature.  The  convulsions  last  but  a 
few  seconds,  sometimes  several  minutes.  The  severity  of  the 
eclampsia  in  the  mother  seems  to  have  no  influence  on  the  frequency 
of  appearance  of  convulsions  in  the  infant.  If  the  children  survive 
the  first  few  days  the  prognosis  is  relatively  good.  The  treatment 
is  to  force  fluids  by  mouth,  per  rectum,  subcutaneously  or  intra- 
venously, in  order  to  dilute  the  circulating  toxins. 

We  have  experienced  severe  toxemia,  as  evidenced  by  stupor 
and  other  nervous  manifestations,  in  both  premature  and  full-term 
infants  fed  on  eclamptic  and  nephritic  mothers'  early  breast  milk. 
To  avoid  this  catastrophe  it  has  become  our  rule  to  examine  the 
infants  very  carefully  for  toxic  symptoms  and  in  their  presence 
to  feed  all  such  prematures  human  milk  obtained  from  healthy 
women,  during  the  first  days  or  weeks  of  life. 

PYELOCYSTITIS. 

The  appearance  of  an  infectious  process  in  the  urinary  tract,  as 
pyelocystitis,  is  as  possible  in  the  newly  born  as  in  older  nurslings. 
Although  general  infections  appear  relatively  easily  in  the  first  days 
of  life,  nevertheless,  clinical  symptoms  are  often  lacking.  The 
presence  of  chills,  fever  and  sweats,  as  noted  in  older  children,  is 
seldom  observed  in  the  first  days  of  life,  so  that  the  diagnosis  is 
only  made  by  urinary  examination,  disclosing  blood,  albumin,  pus 
cells  in  large  numbers  and  not  infrequently  colon  bacilli. 

Pushing  of  fluids  and  the  administration  of  potassium  citrate 
to  the  point  of  positive  alkalinization  of  the  urine  are  the  only 
therapeutic  measures  applicable  to  the  premature. 

1  Rev.  di  clin.  Ped.,  1903,  No.  8.  2  Arch.  f.  Kinderh.,  1909,  88,  60. 


CHAPTER  XIII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 

MENTAL  AND  NERVOUS  DISTURBANCES. 

The  frequency  of  mental  disturbances  and  other  phenomena  on 
the  part  of  the  central  nervous  system  in  premature  infants  has 
been  variously  estimated.  Finkelstein  states  that  mental  dis- 
turbances and  spastic  phenomena  are  not  more  frequent  in  pre- 
matures than  in  full-term  infants,  but  Ylppo  strongly  contests 
this  statement.  The  attempt  to  express  the  frequency  of  perma- 
nent mental  defects  and  other  cerebral  disturbances  in  percentages 
is  only  rarely  possible  before  the  end  of  the  first  year  of  life,  with 
perhaps  the  exception  of  the  typical  Mongolian  idiot.  Demon- 
strable mental  defects,  either  complete  idiots  or  imbeciles,  were 
found  in  7.4  per  cent  of  Ylppo 's  cases. 

Mental  defects  in  premature  infants  are  frequently  accompanied 
by  other  symptoms  on  the  part  of  the  central  nervous  system. 
The  most  common  are  the  spastic  paraplegias  and  diplegias.  These 
are  present  in  prematures  with  demonstrable  mental  defects  in 
at  least  75  per  cent  of  all  cases.  However,  mental  development 
may  be  complete  in  the  presence  of  spasticity  of  the  extremities 
dependent  upon  cerebral  irritation.  In  most  instances  this  is 
secondary  to  intracranial  hemorrhage.  Paraplegia  or  diplegia  was 
present  in  3.1  per  cent  of  all  Ylppo's  cases.  These  figures  would 
certainly  be  much  higher,  had  all  the  prematures  remained  alive, 
since  most  of  the  infants  suffering  from  injury  to  the  brain  die  very 
early.  The  cerebral  affections  occur  the  more  frequently,  the 
smaller  the  infant  at  birth. 

In  our  experience  mental  disturbances  and  defects  on  the  part 
of  the  central  nervous  system  have  been  confined  largely  to  those 
infants  who  survived  from  among  the  class  of  so-called  weaklings. 
These  are  the  infants  who  have  suffered  from  intra-uterinc  disease 
or  congenital  malformations,  traumata  at  birth,  or  postpartum 
dietetic  errors  and  infection.  Among  the  more  mature  that  arc 
normal  for  their  fetal  age  the  prognosis  for  a  full  mental  develop- 
ment is  good. 

Treatment.  — In  the  postmortem  examination  of  infants  dying 
of  cerebral  hemorrhage,  Rodda1  found  over  50  per  cent  followed 

1  Am.  Jour.  Dis.  Child.,  1920,  19,  268. 


302  DISEASES  OF  THE  NERVOUS  SYSTEM 

non-instrumental  deliveries  and  many  followed  normal  and  easy 
births.  In  these  cases  the  blood  was  found  slightly  or  not  at  all 
coagulated.  Cerebral  hemorrhage  was  by  far  the  most  frequent 
cause  of  death  in  the  new  born  in  his  group  of  cases.  In  many 
cases  at  postmortem,  no  torn  veins  were  found  in  the  cerebrum 
or  cerebellum  to  account  for  the  hemorrhage,  and  multiple  hemor- 
rhages were  found  in  portions  of  the  body  where  it  was  incon- 
ceivable that  they  could  be  explained  by  trauma.  Over  25  per 
cent  of  all  infants  dying  of  cerebral  hemorrhage  showed  this  picture 
of  multiple  hemorrhages.  An  analysis  of  cases  reported  in  the 
literature  deepened  the  conclusion  that  these  hemorrhages  were 
due  to  factors  other  than  trauma.  Further  study  led  to  the  con- 
clusion that  there  was  a  disturbance  in  the  coagulation  time  of 
the  blood  in  the  new  born.  It  was  found  that  the  average  coagu- 
lation time  in  the  new  born  was  seven  minutes.  In  icterus,  melena, 
jaundice,  syphilis  and  non-traumatic  cerebral  hemorrhage,  the 
coagulation  time  of  the  blood  was  prolonged.  In  melena  it  might 
be  delayed  to  ninety  minutes.  The  subcutaneous  injection  of 
normal  blood  was  effective  in  cases  in  which  there  was  delayed 
or  slow  bleeding. 

The  further  treatment  in  those  cases  with  a  diagnosis  of  intra- 
cranial hemorrhage  is  symptomatic  and  expectant.  There  is 
always  the  possibility  that  there  may  be  spontaneous  cure.  The 
infant  must  be  kept  quiet  and  warm.  For  the  motor  hyper- 
irritability  and  convulsions  narcotics  may  be  employed,  before  all 
chloral  hydrate  (0.12  to  0.5  gm.  per  day  per  rectum),  also  bromides 
(0.25  to  1  gm.  per  day)  or  calcium  lactate  (1  to  2  gm.)  or  calcium 
bromide  (0.3  to  0.5  gm.  per  mouth)  per  day. 

Where  the  infants  do  not  swallow  well,  feedings  must  be  given 
per  catheter  or  subcutaneous  infusions  must  be  used  for  emerg- 
ency. 

Lumbar  puncture,  although  primarily  a  diagnostic  measure, 
may  have  a  beneficial  therapeutic  action.  It  is  of  diagnostic  value 
when  the  hemorrhage  is  below  the  tentorium. 

In  the  full  term,  cranial  decompression  when  employed  early 
has  yielded  favorable  results,  however  little  can  be  expected  from 
such  surgical  interference  in  the  premature. 

Schulze's  swingings  and  other  violent  measures  for  artificial 
respiration  are  distinctly  contraindicated  in  the  treatment  of 
asphyxia  in  the  premature. 

For  the  paraplegias  and  diplegias,  corrective  measures  should  be 
undertaken  early  in  order  to  prevent  marked  deformities.  Massage 
and  active  and  passive  movements  should  be  practised  regularly 
beginning  to  advantage  in  the  first  year. 


HYDROCEPHALUS;  MEGACEPHALUS  303 

Muscle  training  in  walking,  climbing  and  other  activities  should 
be  instituted  under  the  supervision  of  a  trained  assistant. 

Orthopedic  appliances  are  frequently  indicated. 

Surgical  procedures  may  be  necessary  later. 

Another  group  is  made  up  of  premature  infants  with  more  or 
less  serious  mental  defects  in  whom  typical  epilepsy  gradually 
develops,  often  of  the  Jacksonian  type.  It  is  very  difficult  and 
often  impossible  to  make  a  differential  diagnosis  between  epilepsy 
and  spasmophilia  in  the  first  attacks,  and  especially  in  those  cases 
where  the  convulsions  appear  very  early.  Fortunately,  ;i-  ;i 
general  rule,  the  epileptic  convulsions  do  not  occur  in  the  Grsl 
year  of  life  in  prematures,  while  on  the  other  hand  electric  hyper- 
irritability  and  spasmophilic  convulsions  are  quite  frequent  in  this 
period  of  life.  This  makes  the  differential  diagnosis  somewhat 
easier. 

On  the  other  hand,  however,  in  connection  with  febrile  diseases 
of  later  life,  convulsions  occur  very  frequently  in  premature  infants. 
Only  the  further  course  of  the  disease  will  show  whether  the  con- 
vulsions are  of  epileptic  or  spasmophilic  nature. 

HYDROCEPHALUS ;  MEGACEPHALUS. 

True  congenital  hydrocephalus  is  usually  of  the  internal  type 
with  enlarged  ventricles.  The  external  form  is  very  rare.  Mega- 
cephalus  must  be  differentiated  from  hydrocephalus,  the  two  often 
being  confused  in  the  premature,  as  previously  mentioned  in  the 
discussion  of  Pathology  and  Rachitis  (pp.  104,  336).  Internal 
hydrocephalus  results  from  a  transudation  or  exudation.  Obstruc- 
tion to  the  outflow  may  be  the  cause  as  in  the  case  of  intracranial 
hemorrhage  or  cerebellar  cysts.  However,  most  of  the  case-  arc 
probably  due  to  an  intra-uterine  serous  meningitis  or  meningo- 
encephalitis of  unknown  origin.  Syphilis  is  frequently  the  cause  of 
congenital  hydrocephalus, 

The  inflammatory  process  bringing  about  hydrocephalus  may  be 
at  end  by  the  time  of  completion  of  pregnancy,  but  usually  persists 
thereafter.  Most  of  the  infants  show  enlargement  of  the  head 
soon  after  birth  or  the  enlargement  becomes  apparent  at  a  later 
period.  When  the  process  begins  early,  intra-uterine,  it  may  bring 
about  a  marked  retardation  in  brain  development.  The  head  need 
not  necessarily  be  enlarged;  indeed  the  head  may  he  small  a-  in  a 
microcephalic.  The  brain  in  these  cases  is  really  a  large  cyst.  ( )l'ten 
the  skull  is  enlarged  at  birth,  and  it  may  hinder  labor  to  such  an 
extent  that  perforation  or  puncture  of  the  head  become>  acces- 
sary. 


304 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Where  the  head  has  the  classic  hydrocephalic  configuration  the 
diagnosis  is,  of  course,  easy.     In  many  instances  there  are  also 


Fig.  162 


Fig.  163 
Figs.  162  and  163.— Megacephalus.     Baby  P.  H.  at  four  months.     Baby  P.  H. 

at  six  months. 


the  following  symptoms  at  birth:  Hypertonus  and  spasms  of  the 
muscles,  increased  reflexes,  convulsions,  psychic  disturbances  and 
apathy. 


HYDROCEPHALUS;  MEGACEPHALUS 


305 


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306 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Measurements. 


Age,  23  days. 

Dates April  23 

Weight 725  gm. 

Length 31.0  cm. 

Occipitofrontal      .      . 

Diameters: 

Biparietal  ....  7.5  " 
Bitemporal  .  .  .  6.5  " 
Occipito-mental  .  .  7.0  " 
Suboccipito  bregmatic      6.5     " 

Circumference: 

Occipto-frontal  .  . 
Occipito-mental  .  . 
Shoulders  .... 
Hips 


May  13 
922  gm. 
36.5    cm. 

8.75    " 


8.0 

7.5 

10.0 

6.0 

27.0 
28.0 
20.0 
16.5 


June  20 

1200  gm. 

38.0    cm. 

9.5       " 


8.75 
7.0 
11.5 
8.0 

30.75 
33.0 
25.75 
20.0 


August  28 
1720  gm. 
43.5  cm. 
11.0       " 

10.5  " 

9.75  " 

12.5  " 

9.25  " 

35.0  " 

37.0  " 

28.0  " 

22.0  " 


^Yhere  the  characteristic  head  is  not  seen  and  only  slight  enlarge- 
ment of  the  fontanelle  areas  is  noted,  the  diagnosis  is  difficult. 
Intracranial  hemorrhage  and  meningitis  must  be  ruled  out.  Lum- 
bar or  ventricular  puncture  is  of  great  assistance. 


Fig.  165. — Hydrocephalus.     First  signs  when  infant  was  four  weeks  old. 


The  prognosis  is  usually  difficult  to  make  early.  The  only 
early  therapeutic  measure  is  lumbar  or  ventricular  puncture  with 
drawing  off  of  cerebrospinal  fluid.  Late  surgical  interference  may 
be  indicated. 


H  YDROCEPHALUS;  MEGA  CEP  II A  L  US 


307 


Fig.  166. — Oxycephalus  (Tower  skull).  Usually  associated  with  other  congenital 
defects  and  stigmata  of  degeneration.  The  skull  is  dome  shape  with  bulging  tem- 
poral regions.  The  deformity  was  present  at  birth.  It  is  generally  associated  with 
exophthalmos,  proptosis  and  frequently  with  other  ocular  abnormalities.  Some 
children  arc   mentally   normal.     Others  subnormal. 


The  term  megacephalys  is  applied  to  the  conditions  in  which  the 
head  develops  out  of  proportion  to  the  other  body  measurements 
and  length.  It  is  characterized  by  an  abnormally  large  head,  with 
a  relatively  larger  brain.  This  condition  is  a  characteristic  finding  in 
a  high  percentage  of  infants  prematurely  born  and  is  seen  in  inverse 
proportion  to  the  fetal  age  and  birth  weight.  Rosenstern,1  in  a 
series  of  sixty-one  prematures  observed  over  a  period  of  at  least 
three  months,  noted  megacephalus  in  forty-four.  lie  concluded 
that  the  lower  the  birth  weight  of  the  premature  the  more  likely  is 
megacephalus  to  develop, 

RELATION  OF  BODY  WEIGHT  TO  MEGACEPHALUS  (ROSENSTERN 


Birth  weight. 

Present . 

Absent 

Severe. 

Moderate 

Mild, 

Total. 

In  1000  gm.         .      . 

1 

0 

1 

it 

1 

n 

1001    "   1500    "           .      . 

12 

5 

(i 

1 

12 

0 

L501    "  '-'()()()    "           .      . 

21 

3 

14 

1 

1^ 

;; 

2001   "  2500    "           .      . 

27 

1 

9 

3 

13 

14 

Total 

61 

44 

17 

1  Rosenstern,  J.:     Ztschr.  f.  Kinderh.,  1922,  22,  129. 


308 


DISEASES  OF  THE  NERVOUS  SYSTEM 


It  usually  occurs  before  the  age  at  which  rachitic  changes  are 
noted  in  the  long  bones  and  chest.  However,  as  rickets  occurs 
much  earlier  in  premature  infants  than  in  full-term  infants,  I  do  not 
believe  that  we  are  at  present  in  a  position  to  dissociate  these  two 
conditions.  There  is  therefore  great  probability  that  the  same 
etiological  factors  underlying  the  development  of  megacephalus 
in  the  first  months  may  be  the  cause  of  rachitic  manifestations  in 
the  bones  and  other  organs  at  later  periods. 

TIME   OF   OCCURRENCE   OF  MEGACEPHALUS    (ROSENSTERN) . 


Age  in 
months. 

Cases. 

Age  in 
months. 

Case 

1    .       .       . 

.      .      .        9 

6   .      .      .      . 

.      .      .      0 

2 

.      .      .      11 

7  .      .      .      . 

.      .      .      1 

3    .      .      . 

.      .      .      11 

8  .      .      .      . 

.      .      .      1 

4   .      .      . 

.      .      .        0 

9-11    .      .      . 

.      .      .     0 

5   .      .      . 

.      .      .        4 

12   ...      . 

.    .    .    1 

It  is  most  frequently  first  seen  during  the  second  and  third  months 
of  life  and  reaches  its  maximum  between  the  sixth  and  eighth 
months.  It  then  gradually  becomes  less  manifest.  There  is  usually 
an  increased  spinal  fluid  pressure  in  which  it  resembles  hydro- 
cephalus. The  brain,  on  section,  is  found  to  be  abnormally  large 
but  in  true  cases  there  is  a  complete  absence  of  hydrocephalus. 

Associated  with  the  large  skull  and  wide-open  fontanelles  and 
sutures,  exophthalmos  is  frequently  seen.  The  latter  probably 
results  from  the  lack  of  skull  capacity,  the  eyes  being  protruded, 
with  prominent  cornea  and,  not  infrequently,  dilated  pupils.  Further 
characteristics  of  the  head  are  a  broad  face,  and  mouth,  nose  and 
eyes  which  appear  closely  set  together :  the  nose  is  stumpy  and  small 
and  rises  but  little  above  the  face;  the  tongue  is  often  large  and 
protruded. 

ENCEPHALITIS. 

The  subject  of  encephalitis  of  the  premature  and  full-term  new 
born  is  still  very  much  in  the  dark.  The  etiology  is  obscure  and 
a  clinical  picture  for  the  encephalitic  processes  has  not  yet  been 
described. 

Encephalitis  interstitialis  congenita  was  described  by  Virchow,1 
with  changes  in  the  medullary  substance  of  the  cerebrum,  as  a 
diffuse  infiltration  with  fatty  granular  cells.  Later,  other  observers 
declared  that  this  was  not  pathological  (Jastrowitz,2  Limbeck3). 
Brain  defects   (porencephaly)   have  been  linked  with  congenital 


1  Virchow's  Arch.,  1867,  38,  129. 

2  Arch.  f.  Psych.,  1870,  vol.  2  and  1871,  vol.  3. 

3  Prague  Ztschr.  f.  Heilk.,  1885,  7,  87. 


MENINGITIS  309 

encephalitis.  Septic  encephalitis  is  either  a  metastatic  condition 
or  a  meningoencephalitis,  the  difference  between  the  two  being 
almost  impossible  to  define.  The  medullary  substance  shows 
clumps  of  bacteria  and  leukocytes,  and  later  there  appears  a  sup- 
purative inflammation  on  the  brain  substance.  Not  infrequently 
in  prematures  the  meningo-encephalitis  is  a  distinctly  luetic  process 
(see  Syphilis  in  Prematures,  p.  330). 

MENINGITIS. 

The  meningitic  processes  are  as  little  understood  as  the  encepha- 
litic.  They  may  be  acute  or  chronic.  Serous  meningitis  which  is 
not  well  understood  is  supposed  to  be  intimately  related  to  con- 
genital hydrocephalus.  Pachymeningitis  hemorrhagica  interna 
seems  to  be  a  luetic  process  entirely  (see  Syphilis  of  Prematures,  p. 
330). 

Purulent  meningitis  follows  suppurative  conditions  in  the  mid- 
dle ear,  accessory  nasal  sinuses  or  is  metastatic.  Sometimes  one 
sees  typical  meningeal  symptoms  as:  Convulsions,  rigidity  of  the 
neck,  hypertonus,  protruding  fontanelles.  However,  meningitis 
may  be  present  without  any  characteristic  signs.  The  infants  are 
flaccid,  exhausted,  and  dried  out.  The  diagnosis  is  verified  by 
lumbar  puncture.     Fever  is  often  absent  or  only  present  terminally. 

The  prognosis  is  absolutely  poor.  Death  usually  follows  in 
twenty-four  hours,  but  some  linger  eight  to  fourteen  days.  The 
inception  of  the  process  is  difficult  to  fix  because  of  the  uncertainty 
of  the  symptoms. 

Sinus  thrombosis  following  middle-ear  infections  or  phlebitis  after 
navel  infections  sometimes  are  responsible  for  the  meningitis. 

Epidemic  cerebrospinal  meningitis  is  not  an  uncommon  compli- 
cation in  premature  infants  during  the  first  year.  A  spinal  puncture 
should  be  made  in  every  case  showing  marked  evidence  of  cerebral 
irritation.  In  positive  cases  serum  should  first  be  administered 
intravenously  through  the  longitudinal  sinus,  because  of  the  ten- 
dency to  generalization  of  the  infection  in  this  class  of  infants. 
Intraspinal  administration  of  serum  must  always  be  made  by  the 
gravity  method  after  withdrawal  of  as  much  fluid  as  is  to  be  admin- 
istered. 

Finally  we  find  among  the  prematures  a  number  of  idiots  that 
have  to  be  classified  as  "degenerative  idiots."  These  are  the 
infants  that  at  birth  already  show  stigmata  of  Mongolism  or  other 
malformations.  These  children  are  prematurely  born  with  special 
frequency,  and  it  follows  therefore  that  a  considerable  number  of 
children  with  Mongolian  idiocy  are  prematures.  After  all,  it  is  a 
known  fact  that  children  with  various  congenital  malformations, 


310  DISEASES  OF  THE  NERVOUS  SYSTEM 

be  they  congenital  bone  diseases,  bone  anomalies,  congenital 
heart  disease,  malformations  of  the  brain  or  spinal  cord,  etc.,  are 
born  in  an  immature  condition.  This  circumstance,  as  previously 
mentioned,  is  the  reason  that  prematures  have  been  very  generally 
but  erroneously  regarded  as  congenitally  inferior. 

SPASMOPHILIC  CONVULSIONS. 

With  reference  to  spasmophilic  convulsions  we  must  not  regard 
them  as  purely  functional  convulsions;  on  the  contrary  the  readi- 
ness with  which  they  occur  and  their  frequency  in  premature 
infants  speaks  very  strongly  for  organic  lesions,  probably  most 
frequently  among  these  being  cerebral  hemorrhage  occurring 
during  labor.  Naturally  certain  extra-uterine  noxse,  as  anemia 
and  rachitis,  are  of  importance  as  determining  factors  that  make 
the  spasmophilic  disturbances  manifest.  Numerous  roentgeno- 
logical examinations  of  the  long  bones  of  premature  infants  have 
shown  that  the  rachitic  changes  are  not  confined  to  the  skull,  but 
that  the  other  bones  are  also  early  affected,  as  early  as  the  second 
and  third  months  of  life.     (See  p.  347.) 


CHAPTER  XIV. 
SEPSIS. 

The  term  sepsis  may  be  defined  as  an  invasion  of  the  system  by 
pyogenic  cocci  or  other  equivalent  organisms.  These  bacteria 
may  attain  entrance  through  various  atria  and  may  spread  by 
means  of  the  blood  stream  or  may  remain  at  the  point  of  invasion 
and  from  there  discharge  the  products  of  their  activity  into  the 
blood  of  the  infant. 

Bacteriology.— The  bacteria  occupying  the  first  place  among  those 
causing  sepsis  are  the  pyogenic  cocci,  the  streptococcus  and  staphylo- 
coccus, both  albus  and  aureus.  With  them  may  be  included  the 
pneumococcus  and  colon  bacillus.  The  colon  group  includes  the 
paracolon  and  paratyphoid  varieties.  Of  other  bacteria  there 
are  found  more  rarely  the  Bacillus  pyocyaneus,  Bacterium  laetis 
aerogenes,  Bacillus  enteritidis  (Gartner),  proteus  bacillus,  the 
gonococcus,  the  influenza  bacillus  and  the  meningococcus.  Infec- 
tion with  Treponema  pallidum   is  treated  as  a  specific  disease. 

Blood  examination  during  life  and  immediately  after  death  in 
cases  of  sepsis  in  the  premature  gave  the  following  results:1 

Blood  culture  positive 15 

Blood  culture  negative 4 

Percentage  positive 75.3  per  cent 

Streptococcus 6  times 

Colon  bacillus 5 

Staphylococcus 1 

Pneumococcus 1 

Influenza  bacillus 1 

Colon  bacillus  and  influenza  bacillus 1 

Ylppo,2  in  a  small  series  of  prematures,  found: 

BACTERIA   IN  BLOOD   OF   PREMATURES 

Age,  No.  of  Bacteria 

days.  found. 

0  to     1 8  0 

2  to    3 7  2 

4  to  15 14  10 

1  Delestre:     Infections  chez  le  pr&nature,  Paris,  1901. 

-  Pathologiach-anatomischi   Studien  bei  Fruhgeburten,  Ztschr.  f.  Kinderh.,  1919, 

20,  371-372. 


312  SEPSIS 

In  70  per  cent  of  the  infants  perishing  between  the  fourth  and 
fifteenth  day  of  life,  Ylppo  was  able  to  demonstrate  bacteria  in 
the  blood.     In  12  cases  the  following  organisms  were  noted: 

Bacillus  coli 6  times 

Staphylococcus 3      " 

Streptococcus     1      " 

Not  identified 2      " 

The  frequency  of  Bacillus  coli,  he  believes,  speaks  for  an  internal 
basis  for  the  infection. 

The  Time  of  Infection.— This  may  be  either  intra-uterine,  intra- 
partum or  postpartum  (extra-uterine).  Intra-uterine  infection  may 
occur  either  through  the  placenta,  or  by  way  of  the  liquor  amnii. 
Should  the  mother  be  suffering  from  a  septic  infection,  the  causative 
organisms  may  pass  through  the  injured  placental  wall,  which 
ordinarily  is  sufficient  to  exclude  bacteria  from  the  fetus. 

Infection  of  the  liquor  amnii  may  occur  before  or  after  the 
rupture  of  the  membranes.  Before  rupture  the  infection  may 
occur  by  contiguity  of  tissue,  the  organisms  coming  from  the 
peritoneal  cavity,  rectum  or  bladder.  Infection  through  the 
vaginal  canal  with  unruptured  membranes  probably  does  not 
occur,  the  cervical  opening  being  obstructed  by  what  Delestre1 
calls  the  "gelatinous  stopper  of  pregnancy."  Vaginal  infection, 
therefore,  usually  stops  beneath  the  internal  os.  But  once  the 
membranes  rupture,  infection  can  occur  by  the  ascension  of  bacteria 
from  the  vagina.     This,  however,  is  uncommon. 

Our  knowledge  of  infection  through  the  liquor  amnii  is  more 
definite.  Lehmann2  states  that  bacteria  can  pass  through  uninjured 
membrane  and  reports  cases  in  support  of  this  statement. 

Intrapartum  infectio?is  occur  during  the  passage  of  the  infant 
through  the  maternal  birth  canal.  Local  infection  occurs  first 
and  this  may  be  followed  by  general  sepsis.  The  atrium  of  infec- 
tion may  be  the  mouth,  the  digestive  tract,  the  lungs  after  aspira- 
tion of  infected  vaginal  mucus  or  amniotic  fluid,  or  wounds  of  the 
skin.  The  eyes  especially  are  subject  to  infection  at  the  time  of 
birth,  but  fortunately  infection  there  remains  local. 

Post  partum,  the  most  important  sources  of  entrance  of  infection 
are  the  umbilicus,  the  skin,  the  gastro-intestinal  tract  and  the  respi- 
ratory apparatus.  As  compared  with  intra-uterine  and  intra- 
partum infections  those  of  extra-uterine  origin  are  much  the  most 
important. 

Umbilical  infections  through  the  physiological  wound  made  at 
the  time  the  cord  is  severed  are  the  most  frequent  of  all  infections 

1  These,  A  Study  of  the  Infections  of  the  New  Born,  Paris,  1901. 

2  These,  De  l'infection  amniotique  et  de  ses  consequences  pour  18  enfants,  Paris, 
1899. 


THE  TIME  OF  INFECTION  313 

after  birth  and  this  forms  the  most  common  portal  of  entry  for 
sepsis.  At  birth  the  most  important  structures  found  in  the 
umbilical  cord  are  the  two  umbilical  arteries  which  conduct  the 
blood  from  the  fetus  to  the  placenta,  and  which  arise  from  the 
common  iliac  arteries,  and  the  umbilical  vein  which  carries  blood 
from  the  placenta  to  the  inferior  vena  cava  via  the  left  branch  of 
the  portal  vein  and  the  ductus  venosus  arantii.  Immediately 
after  birth  the  cord  is  ligated  and  cut,  there  remaining  a  stump  a 
few  centimeters  in  length  which  undergoes  desiccation  during  the 
first  few  days  of  life  and  which  separates  on  the  fourth  to  the  ninth 
day  with  a  slight  inflammatory  reaction.  In  the  premature  and 
debilitated  the  falling  off  of  the  cord  and  subsequent  cicatrization 
of  the  base  often  occurs  later.  Ordinarily  the  base  is  covered 
by  epithelium  by  the  end  of  the  third  week  or  a  little  before,  but 
infection  of  the  umbilical  wound  may  occur  at  any  time  up  to  the 
moment  of  healing,  and  is  especially  common  in  prematures. 

Of  second  importance  as  a  gateway  for  the  entrance  of  patho- 
genic bacteria  is  the  shin.  .The  frequent  abrasions  which  occur 
during  birth,  erosions  from  too  severe  efforts  at  mechanical  cleans- 
ing, the  pemphigus  lesions  and  the  intertrigo  so  common  in  the 
neglected  weaklings,  all  form  portals  of  entry  for  bacteria.  In 
the  premature  especially  the  skin  is  delicate,  lacking  the  horny 
layer  which  in  the  better  developed  tends  to  prevent  the  occur- 
rence of  abrasions.  Furunculosis  and  abscess  formation  are  often 
the  precursors  of  a  general  infection. 

The  respiratory  tract  is  a  frequent  means  of  entry  through  the 
occurrence  of  a  simple  or  suppurative  rhinitis,  otitis  media,  bron- 
chial infection  with  epithelial  necrosis  or  bronchopneumonic  inflam- 
mation. It  must  be  remembered  that  pulmonary  inflammations  are 
prone  to  develop  secondarily  in  sepsis  and  unless  evidence  of  pul- 
monary affection  can  be  shown  early  in  the  course  of  sepsis,  it 
may  be  difficult  to  say  whether  it  was  primary  or  secondary. 

Of  nearly  equal  importance  is  the  gastrointestinal  tract  as  an 
atrium  of  infection.  The  buccal  mucosa  may  be  the  seat  of  mucous 
patches,  of  Bednar's  aphthae  on  the  palate,  of  thrush,  of  stomatitis, 
or  gingivitis,  of  ulcerations  from  too  vigorous  cleansing,  or  of 
abrasions  due  to  the  passage  of  the  tracheal  catheter.  The  intestinal 
wall  of  the  premature  and  even  the  full- term  newly  born  weaklings 
may  be  permeable  to  bacteria  which  cannot  pass  through  the 
intestinal  wall  of  better  developed  infants. 

We  believe  that  though  the  gastro-intestinal  tract  is  frequently 
the  seat  of  ulceration  in  the  stage  of  atrophy  in  infants,  a  condition 
more  rapidly  developing  in  the  prematures  than  in  full-term  infants, 
and  therefore  offering  numerous  portals  of  entry  for  systemic  infec- 


314  SEPSIS 

tion,  every  attempt  should  be  made  to  exclude  all  other  atria 
before  accepting  the  gastro-intestinal  tract  as  the  source  of  infection. 

Genito-urinary  infections  are  of  importance  as  the  source  of 
sepsis  in  the  premature  newborn. 

Susceptibility. —The  premature  is  especially  receptive  to  infection 
with  the  organisms  of  sepsis,  seemingly  possessing  an  extremely 
low  resistance.  The  organs  in  which  the  leucocytes  are  formed  are  but 
imperfectly  developed  and  the  leucocytes  themselves  are  deficient 
in  phagocytic  power;  other  organs  are  incomplete,  the  individual 
cells  are  immature  and  the  lymph  glands  are  of  little  importance 
in  these  infants,  and  fail  to  enlarge  in  the  presence  of  infection. 

The  frequent  subnormal  temperature  of  these  weaklings 
encourages  this  ease  of  infection,  experimental  evidence  showing 
that  to  lower  the  temperature  of  an  organ  is  to  lower  its  resistance, 
and  diminish  phagocytic  activity  and  the  bactericidal  energy  of 
the  blood.  Without  doubt  there  is  also  a  deficient  formation  of 
antibodies  in  these  premature  infants  (Pfaundler.1) 

Artificially-fed  prematures  possess  a  relatively  greater  suscepti- 
bility to  septic  infection  than  do  breast-fed  infants,  a  fact  which 
may  in  part  be  explained  by  the  fact  that  human  milk  is  rich  in 
protective  substances  in  contradistinction  to  cow's  milk. 

In  sepsis  the  difference  between  the  infants  born  of  healthy 
parents  and  those  of  diseased  parents  is  marked.  The  healthy 
premature  is  formed  of  young  cells,  full  of  vitality  and  only  requir- 
ing growth  to  perfect  themselves,  and  capable  to  some  degree  of 
resisting  the  organisms  of  infection  with  which  they  are  continually 
surrounded.  The  others  are  already  affected  by  the  toxemia  of 
the  parental  disease,  or  are  themselves  directly  involved,  and 
thus  their  cells  have  their  vitality  reduced  and  so  offer  a  medium 
already  prepared  for  infection. 

The  frequency  of  sepsis  among  the  new  born  is  today  very  much 
less  than  it  was  in  preaseptic  days.  Proper  care  of  the  hands 
and  the  conduct  of  labor,  sterilization  of  instruments  and  dressings, 
has  greatly  reduced  the  incidence  of  this  condition.  The  fact  that 
infants  tend  more  often  to  become  septic  in  a  hospital  or  asylum 
than  in  the  home  is  to  be  accounted  for  by  the  greater  frequency 
of  infecting  organisms  in  the  former,  where  many  sick  are  con- 
gregated, and  by  the  fact  that  one  attendant  often  cares  for  several 
infants  in  the  same  hospital  or  ward  (Meyer2). 

General  Manifestations.— The  onset  of  sepsis  may  occur  at  any 
time  during  the  first  days  of  life  or  the  infant  may  be  born  with  an 
infection  present.     The  course    varies,  some  almost  without  any 

1  Die  Antikorperiibertragung  von  Mutter  auf  Kind,  Arch.  f.  Kinderh.,  1908,  47, 
260;     1908,  48,  245. 

2  Hospitalismus,  Berlin,  1913;     Ges.  f.  Gynak.,   1911. 


GENERAL  MANIFESTATIONS  315 

symptoms  which  can  be  interpreted  as  involving  any  one  set  of 
organs,  death  occurring  suddenly  after  collapse. 

Local  symptoms,  if  present,  are  dependent  upon  the  situation 
of  the  primary  infection  or  of  secondary  metastatic  foci,  while 
the  general  symptoms  are  those  of  a  septicemia. 

The  septic  fever  in  the  premature  infant  does  not  possess  those 
characteristics  found  in  older  children.  The  center  for  heat  regu- 
lation lacks  stability  and  the  reaction  to  toxic  influences  is  slight. 
The  more  robust  infants  may  show  a  rise  of  temperature  which 
may  reach  105°  F.  or  even  higher,  and  which  may  run  a  more  or  less 
regular  course.  In  those  born  considerably  before  term,  and  in 
the  weaklings  there  may  be  little  or  no  temperature  reaction,  in 
fact  in  these  latter  a  subnormal  temperature  is  the  rule,  (hills 
do  not  occur  in  these  weaklings. 

Loss  of  weight  is  likely  to  be  rapid  and  great,  depending  upon 
the  ability  to  take  food  and  the  degree  of  intestinal  involvement, 
being  due  to  disintegration  of  tissue,  to  loss  of  water,  and  to  ina- 
bility to  take  food  and  fluids.  The  pulse-rate  is  rapid  and  the 
quality  is  usually  poor.  Respirations  are  often  irregular.  Cere- 
bral symptoms  are  common  during  the  final  stages,  the  infant  has 
a  prostrated  appearance  and  is  apathetic.  The  cry  becomes  more 
feeble  and  the  movements  less  frequent  than  usual.  The  skin 
loses  its  turgor;  anemia  becomes  evident  and  the  skin  color  becomes 
grayish  or,  if  icterus  exists,  yellowish.  Occasionally  there  is  a 
cyanotic  tinge  to  the  entire  body  surface.  Hemorrhages  are  very 
common  during  the  course  of  sepsis,  occurring  from  the  mouth, 
bowel,  navel  or  into  the  skin. 

Shin.— Icterus  is  a  very  frequent  finding  in  the  first  few  days 
or  weeks  of  life  and  is  especially  frequent  in  premature  infants  and 
in  the  victims  of  sepsis.  Particularly  with  umbilical  infections  is 
the  icterus  of  marked  degree.  Edema  of  the  feet  and  legs  occa- 
sionally occurs  and  expecially  in  premature  infants  scleredema,  or 
even  sclerema,  may  occur  toward  the  end  of  the  disease.  Hemor- 
rhages into  the  skin  are  common  in  sepsis,  being  seen  over  the 
trunk  and  extremities,  usually  as  petechia3.  In  some  instances 
they  may  be  purpuric,  or  effusive  in  character.  Pemphigus-like 
blebs  with  bloody  contents  are  a  frequent  complication. 

Inflammation  of  the  umbilical  vessels  is  a  frequent  primary  pro- 
cess in  a  general  sepsis.  Most  often  the  umbilical  arteries  are 
involved,  and  less  frequently  the  vein.  The  amount  of  involvement 
varies,  occasionally  extending  just  a  short  distance  within  the 
abdominal  wall,  sometimes  the  entire  length  of  the  vessel,  in  which 
latter  instance  the  thickened  vessel  cannot  infrequently  be  palpated 
through  the  abdominal  wall.  Septic  thrombi  or  pus  may  be 
present  in  the  umbilical  vessels,  and  pus  can  often  be  squeezed  out 


316  SEPSIS 

from  the  stump  of  the  cord.  Inflammation  of  the  umbilicus  or  of 
the  abdominal  wall  in  its  immediate  neighborhood  may  be  present. 

Omphalitis  alone  is  sometimes  seen.  The  usual  termination  of 
this  infection  is  in  abscess  formation,  but  occasionally  an  inflamma- 
tion of  an  erysipelatous  character  spreads  to  the  abdominal  wall 
(Holt1). 

Nervous  symptoms  are  many.  They  may  depend  solely  upon 
the  toxemia,  or  be  due  to  an  intercurrent  meningitis,  encephalitis 
or  edema  of  the  meninges.  Most  often  the  infant  lies  quietly  in 
a  stuporous  condition,  at  other  times  there  are  restlessness,  tremors, 
spasms,  jactitation,  dilated  pupils,  bulging  fontanel,  spasticity  of 
the  muscles  with  rigidity  of  the  neck,  and  in  cases  of  meningitis 
and  encephalitis,  paralyses. 

G astro-intestinal  manifestations  are  practically  always  present. 
In  the  mouth  are  seen  ulcers,  fissures,  stomatitis  and  purulent 
inflammations  of  the  salivary  glands.  Not  infrequently  sepsis 
will  run  its  course  with  clinical  pictures  of  dyspepsia  with  secondary 
anhydremic  intoxication,  with  vomiting  and  diarrhea  as  marked 
symptoms.  The  vomiting  and  diarrhea  are  manifestations  of  the 
toxemia,  emesis  being  frequently  cerebral  in  origin.  The  mesenteric 
glands  are  infiltrated  and  the  gastric  and  intestinal  mucosa  are  the 
seat  of  hemorrhages  and  frequently  show  evidence  of  inflammation. 

Peritonitis  is  a  rather  frequent  complication,  either  general  or 
local.  Oftentimes  it  is  accompanied  by  an  umbilical  inflammation. 
Many  cases  are  purulent,  fluid  being  present.  Adhesions  of  intesti- 
nal coils  to  each  other  or  to  the  abdominal  wall  occur.  The  symp- 
toms of  this  condition  are  abdominal  distention  and  rigidity  with 
tenderness,  vomiting,  umbilical  protrusion,  thoracic  respiration  and 
flexion  of  the  thighs.  Diagnosis  of  the  condition  is  not  at  all  easy 
as  the  presence  of  fluid  is  difficult  to  demonstrate.  Probably  the 
finding  of  greatest  value  in  these  infants  is  abdominal  tenderness. 

The  spleen  is  usually  enlarged.  The  liver  shows  evidence  of  an 
acute  hepatitis,  and  not  infrequently  there  are  multiple  foci  of 
suppuration. 

Involvement  of  the  circulatory  apparatus  in  sepsis  does  occur 
but  is  not  very  frequent.  Pericarditis  is  commoner  than  endo- 
carditis.    The  former  usually  arises  by  extension  from  the  pleura. 

The  myocardium  is  frequently  the  seat  of  parenchymatous 
degeneration  and  hemorrhage. 

The  respiratory  organs  are  involved  very  frequently  in  the  picture 
of  sepsis.  Pneumonia  is  the  most  frequent  lesion  met  with,  and 
as  usual  in  the  weakling  or  premature,  is  difficult  of  diagnosis, 
especially  when  the  process  in  the  lung  is  not  extensive,  with  lesions 

1  Diseases  of  Infancy  and  Childhood,  D.  Appleton  and  Company,  New  York,  191.3. 


GENERAL  MANIFESTATIONS  317 

small  and  multiple.  The  lungs  show  areas  of  bronchopneumonia, 
areas  of  atelectasis,  alveolar  fatty  degeneration,  hemorrhages  into 
the  alveolar  walls  of  multiple  abscesses.  Effusion  into  the  pleura 
is  uncommon. 

Rapid  respiration  and  cyanosis  are  about  the  only  symptoms 
which  are  seen  in  these  cases  of  pneumonia.  Occasionally  the 
rapidity  of  breathing  may  occasion  the  belief  that  the  lungs  are  the 
seat  of  a  pneumonic  process,  when  its  presence  is  only  the  result 
of  severe  intoxication. 

The  kidneys  usually  show  parenchymatous  degeneration  and 
hemorrhagic  nephritis,  with  occasional  necrosis  of  the  epithelium 
and  pyelitis.  The  albumin  which  is  found  in  the  urine  is  either 
the  result  of  the  action  of  the  absorbed  toxins  on  the  kidneys  or 
is  the  expression  of  the  nephritis  or  pyelitis.  In  nephritis  there 
will  be  found  hyalin,  epithelial  or  granular  casts,  and  in  pyelitis, 
pus  cells  and  epithelium. 

Bones  and  Joint  Inflammations.  — Rarely  the  bones  are  involved 
in  an  osteomyelitis  and  the  joints  are  sometimes  the  seat  of  acute 
suppuration,  usually  several  being  involved  at  the  same  time. 
Immobility  and  swelling  over  the  involved  joints  are  the  common 
symptoms  seen.  Pain  is  present  and  crepitus  can  be  elicited  when 
epiphysial  separation  has  occurred. 

Unfortunately  the  blood  is  of  little  value  in  completing  the 
diagnosis,  because  of  the  usual  absence  of  leucocytosis.  A  positive 
diagnosis  is  possible  by  finding  the  causative  organism  in  the  blood. 
The  difficulties  to  be  met  in  making  blood  cultures  in  premature 
infants  must  be  remembered.  The  longitudinal  sinus  is  the  best 
source  for  obtaining  blood. 

Course.— In  the  premature  the  course  is  usually  acute.  Often 
the  first  symptom  is  loss  of  appetite;  the  child  refuses  to  take 
the  breast,  or  if  artificially  fed,  it  vomits.  Convulsions  may 
usher  in  the  condition,  followed  by  icterus  which  increases  in 
intensity  and  soon  is  accompanied  by  diarrhea.  Cyanosis  may 
next  make  its  appearance,  the  accompanying  dyspnea  being  hard 
to  detect  because  of  the  slight  amplitude  of  the  respiratory  move- 
ments. It  is  sometimes  revealed  by  movements  of  the  alse  nasi 
or  by  an  increased  frequency  of  respiration,  or  by  change  in  the 
respiratory  rhythm,  consisting  of  short  inspirations  followed  by 
relatively  long  expirations.  Occasionally  the  respiration  is  slow, 
feeble  and  superficial,  because  of  the  impermeability  of  the  lungs 
involved  by  atelectasis. 

Some  cases  of  sepsis  prove  fatal  in  a  few  hours;  the  younger 
the  infant  and  the  weaker  the  condition  at  birth,  the  shorter  the 
course  as  a  rule.     Symptomless  sepsis  is  frequent  in  the  premature. 


318  SEPSIS 

Prognosis.— Septic  infection  in  the  very  young  is  a  fatal  disease 
and  the  more  immature  the  infant,  the  worse  the  outlook.  In  the 
lesser  degrees  it  offers  a  grave  prognosis  and  in  the  severer  forms  it 
is  practically  always  fatal.  Involvement  of  a  large  number  of 
organs  makes  the  lethal  outcome  almost  certain. 

Prophylaxis.— Since  the  treatment  of  sepsis  in  the  premature 
new  born  offers  so  little,  it  becomes  of  prime  importance  to  prevent 
the  development  of  the  disease,  and  sepsis  may  be  considered  as 
preventable.  The  vulnerability  of  the  new  born  and  particularly 
of  the  premature  new  born,  who  is  deficient  in  vital  functions,  to 
the  invading  organisms  of  disease  is  notable,  and  the  fact  that 
sepsis  occurs  particularly  in  institutions  makes  the  care  of  these 
infants  of  great  importance. 

Infection  which  reaches  the  child  before  birth  is  beyond  our 
control,  but  subsequent  to  that  time  very  much  may  be  done  to 
prevent  the  disease.  The  care  of  the  umbilical  wound  is  of  great 
importance;  instruments  used  in  dividing  the  cord,  the  cord  tape 
and  dressings  must  all  be  aseptic.  In  hospitals  the  infant  should 
be  kept  in  a  separate  room  from  the  mother,  and  the  same  attendant 
should  not  look  after  both  mother  and  infant.  The  hands  of  the 
attendant  and  of  the  mother  when  she  handles  the  child  must  be 
cleansed  thoroughly  before  the  child  is  touched.  The  nurse  should 
wash  her  hands  after  the  care  of  an  infant  before  passing  to  another 
in  the  nursery.  All  articles  which  come  into  contact  with  the 
infant's  mouth— nipples,  feeders,  spoons,  gavage  tubes,  etc.,  must 
be  sterilized  before  use.  All  utensils  should,  so  far  as  possible,  be 
individual.  The  mouth  of  the  infant  must  not  be  traumatized  and 
all  rough  handling  or  other  body  trauma  must  be  avoided.  The 
breasts  of  the  nursing  mother  must  be  washed  thoroughly  before 
each  nursing  and  protected  between  the  nursing  periods  by  covering 
them  with  thin,  clean  gauze. 

Strict  asepsis  during  delivery  will  do  a  great  deal  toward  reducing 
birth  infection  to  the  smallest  amount,  while  care  in  internal 
examinations  before  delivery  will  do  much  toward  lessening  the 
infections  of  the  amniotic  fluid.  Lochial  secretions  can  become 
the  source  of  infections  and  their  care  is  important.  They  should 
be  disposed  of  at  once. 

In  private  families  where  there  is  not  sufficient  help  and  one 
person  must  attend  to  mother  and  child,  the  infant  must  be  taken 
care  of  first,  and  the  mother  later. 

To  facilitate  cleanliness  the  new-born  infant  should  be  given  a 
a  daily  warm  sponge,  unless  very  weak,  and  the  diaper  should  be 
changed  frequently  to  prevent  the  development  of  intertrigo. 
The  use  of  a  dusting  powder  in  the  skin  folds  often  acts  as  an 
irritant. 


ACTIVE  TREATMENT  319 

The  room  in  which  the  infant  spends  its  time  should  be  kept 
at  a  temperature  warm  enough  to  meet  the  needs  of  its  individual 
development  if  it  is  hypothermic.  The  air  of  its  room  should 
always  be  kept  pure  and  fresh  and  light  freely  admitted.  The 
clothing  of  the  infant  should  be  warm  enough,  but  not  too  heavy, 
being  suited  to  the  surrounding  temperature  and  to  the  individual 
needs  of  the  child.  It  should  not  fit  so  tightly  as  to  prevent  move- 
ment of  the  arms  and  legs. 

Only  the  greatest  cleanliness  of  the  skin  and  umbilicus  will 
prevent  infection.  The  falling-off  of  the  cord  and  the  subsequent 
cicatrization  is,  as  a  rule,  delayed  in  prematures,  and  infection  is 
favored.  Wet  compresses  not  infrequently  macerate  the  delicate 
skin  and  so  dry  or  alcoholic  dressings  are  advised,  best  without 
dusting  powder  which  is  likely  to  cake  and  prevent  absorption  of 
the  exudate. 

The  existence  of  an  angina,  rhinitis,  bronchitis  or  any  other 
form  of  infection,  in  the  mother  or  nurse,  make  the  separation  of 
the  infant  from  the  mother  or  a  change  of  nurses  imperative.  Masks 
must  be  worn  by  all  infected  individuals  coming  in  contact  with  the 
infant. 

Active  Treatment.— This  promises  very  little,  as  we  possess  no 
specific  and  our  efforts  must  be  directed  chiefly  toward  the  treat- 
ment of  individual  symptoms,  as  they  arise.  If  abscesses  occur 
they  must  be  opened  and  drained.  The  strength  must  be  supported 
by  judicious  breast-milk  feeding  if  this  be  possible,  and  by  the  use 
of  stimulants  in  1  to  5-drop  doses  of  brandy  or  whisky  every  two 
hours.  In  collapse  stimulation  must  be  resorted  to,  the  most 
useful  being  camphor-in-oil,  1  to  3  minims  hypodermic-ally.  Spiri- 
tus  ammonia3  aromaticus,  1  to  3  minims  by  mouth,  well  diluted, 
every  three  or  four  hours  is  often  of  benefit.  Infusion  of  digitalis 
or  digalen  in  minimum  doses  may  be  used  to  support  a  failing 
heart. 

Fluids  should  be  pushed  by  mouth  in  the  endeavor  to  dilute  the 
circulating  poison.  Gavage  feeding  should  be  instituted  without 
too  prolonged  delay.  The  use  of  saline  transfusion  has  found 
great  favor  in  recent  years.  Seven-tenths  of  1  per  cent  sodium  chlo- 
ride solution  may  be  injected  subcutaneously  beneath  the  breasts  or 
into  the  loose  areolar  tissue  of  the  interscapular  region  in  quanti- 
ties of  \  to  2  ounces  (15  to  60  cc)  and  repeated  if  indicated.  The 
danger  of  infection  must  be  remembered.  Great  elevations  of 
temperature,  if  present,  are  to  be  controlled  by  tepid  baths  but 
care  must  be  taken  to  avoid  collapse.  Often,  these  premature 
infants  do  not  react  to  infection  with  temperature,  and  in  such 
cases  warm  baths  are  indicated.  Mustard  baths  or  mustard 
compresses  are  of  value  in  collapse. 


CHAPTER  XV. 
SYPHILIS. 

Among  the  most  important  factors  producing  premature  birth 
syphilis  ranks  high.  It  is  even  more  frequently  the  cause  of  intra- 
uterine fetal  death.  The  greater  the  severity  of  the  infection, 
the  greater  is  the  likelihood  of  still  birth;  they  represent  an  over- 
whelming of  the  fetus  by  the  spirochetes.  Infants  who  show 
signs  of  syphilis  at  birth  have  a  very  high  mortality  percentage  and 
in  the  case  of  those  prematurely  born,  almost  all  die.  The  prog- 
nosis is  much  better  in  those  developing  clinical  evidence  one  or 
more  weeks  after  birth. 

Jeans1  found  that  (in  his  out-patient  department) : 

"From  10  to  20  per  cent  of  adult  males  and  about  10  per  cent 
of  married  women  are  syphilitic  and  a  minimum  of  10  per  cent 
of  marriages  involve  a  syphilitic  individual. 

"Seventy-five  per  cent  of  all  the  offspring  in  a  syphilitic  family 
are  infected. 

"In  a  syphilitic  family  30  per  cent  of  the  pregnancies  terminate 
in  death  at  or  before  term,  a  waste  three  times  greater  than  is 
found  in  non-syphilitic  families. 

"Thirty  per  cent  of  all  the  living  births  in  a  syphilitic  family  die 
in  infancy,  as  compared  to  a  normal  rate  of  15  per  cent  in  the 
patients  coining  under  his  observation. 

"About  5  per  cent  of  our  infant  population  is  syphilitic. 

"According  to  St.  Louis  vital  statistics,  3.5  per  cent  of  all  infant 
deaths  are  ascribed  to  lues." 

Premature  infants  do  not  necessarily  show  symptoms  of  lues  at 
birth.  In  fact,  in  the  majority  of  cases  syphilis  becomes  manifest 
only  after  a  latent  period  and  this  may  vary  from  one  week  to  one 
or  more  months.  The  later  the  development  of  the  manifestations 
the  more  likely  is  the  infant  to  be  viable.  Cutaneous  manifesta- 
tions are  usually  preceded  by  coryza,  splenic  enlargement  and 
retarded  progress.  While  some  of  the  infants,  and  this  applies 
more  especially  to  the  later  pregnancies  of  syphilitic  mothers,  may 
be  well  nourished  at  birth,  more  often  the  earlier  pregnancies 
present  a  characteristic  picture,  even  in  the  absence  of  specific 
cutaneous  manifestations.     The  skin  is  flabby  and  wrinkled  and 

1  Am.  Jour.  Syph.,  St.  Louis,  1919,  No.  1,  vol.  3. 


SKIN  ERUPTIONS  321 

the  facial  expression  senile— approximating  the  picture  of  extreme 
marasmus  or  athrepsia  in  older  infants.  This  class  usually  perish 
shortly  after  birth  and  the  postmortem  examination  reveals  marked 
luetic,  visceral  changes. 

Infants  born  with  luetic  eruptions  usually  evidence  a  more  or 
less  marked  degree  of  visceral  change  and  they  run  a  much  more 
serious  course  and  give  a  worse  prognosis.  However,  even  in  the 
premature  the  appearance  of  the  cutaneous  lesions  need  not  neces- 
sarily be  associated  with  marasmus.  This  is  more  especially  true 
in  cases  unassociated  with  deep-seated  visceral  changes,  hence 
the  clinical  picture  of  lues  is  enormously  variable  and  all  transi- 
tions occur  from  the  serious  generalized  syphilis  up  to  the  case 
involving  a  single  organ  or  set  of  organs.  When  lesions  are  present 
at  birth,  one  or  more  of  the  following  are  usually  in  evidence: 
Coryza  (snuffles),  bulla?  on  the  hands  and  feet  and  splenic  tumor. 

Mucous  Membranes.— Coryza  is  most  often  the  first  symptom. 
In  its  onset  it  resembles  an  ordinary  cold  but  is  soon  characterized 
by  its  severity  and  chronicity.  The  discharge  is  profuse,  becomes 
mucopurulent  and  often  tinged  with  blood.  Nasal  obstruction 
results  from  the  formation  of  crusts.  Mouth  breathing  follows 
and  nursing  becomes  difficult.  Pharyngitis  and  laryngitis  are 
usually  associated  with  a  resulting  characteristic  hoarseness  and 
aphonia. 

Mucous  patches  and  ulcerations  "develop  on  the  mucous  mem- 
branes and  at  the  mucocutaneous  surfaces,  especially  at  the  mouth, 
anus,  vulva  and  scrotum. 

Skin  Eruptions.— When  not  present  at  birth  the  skin  eruptions 
usually  follow  the  development  of  the  coryza  but  they  need  not 
necessarily  be  preceded  by  it. 

The  most  common  lesions,  and  which  are  very  rarely  seen  at 
birth,  are  of  two  types,  a  diffuse  more  or  less  generalized  skin 
infiltration.  The  skin  becomes  thickened  and  infiltrated  and 
loses  its  elasticity  and  often  after  a  short  period  the  superficial 
layers  crack.  The  skin  in  greater  part  has  a  waxy'  appearance 
with  interspersed  inflamed  areas,  more  especially  at  the  points 
of  Assuring.  This  characteristic  skin  change  may  involve  the 
entire  body  or  appear  in  isolated  areas,  of  which  latter  the  face 
and  extremities,  more  especially  the  hands  and  feet,  are  more 
likely  to  be  the  seat  of  changes.  About  the  face,  the  region  of 
the  mouth,  nose  and  eyelids  are  the  sites  of  predilection,  with  fre- 
quently resulting  rhagades  in  these  regions.  A  massive  involve- 
ment of  the  face  results  in  a  mask-like  appearance.  Following 
Assuring,  there  frequently  results  an  exudate  with  later  crust 
formation.  When  the  scalp  is  involved  alopecia  usually  results 
and  the  same  may  be  true  when  the  eyelids  are  deeply  infiltrated. 
21 


322 


SYPHILIS 


The  soles  of  the  feet  and  palms  of  the  hands  usually  present  a 
diffuse  infiltration  and  appear  firm  and  shiny,  sometimes  more 
reddish  or  bluish  red,  at  other  times  a  copper-red  or  brown. 

A  true  paronychia,  which  is  often  accompanied  by  complete 
destruction  of  the  nails,  is  an  almost  constant  complication  in  this 
type  of  skin  lesions. 

The  surface  is  either  smooth  or  shows  fissures  in  the  uppermost 
horny  layers  of  the  epidermis,  which  occasionally  sloughs  in  large, 
lamellous  scales. 

In  the  second  type  of  rash  lesions  which  are  more  circumscript 
are  noted.     These  lesions  assume  more  nearly  the  characteristics 


y" 

V. 

>\*»          J 

i 

V, 

'^jRtot  , 

Fig.  167  Fig.  168 

Figs.  167  and  168. — Congenital  syphilis.     Secondary  lesions  on  face,  body  and 
hands  and  feet.     Lesions  first  appeared  during  fourth  week. 


of  the  skin  manifestations  in  acquired  syphilis.  The  most  fre- 
quent type  of  lesions  are  macules  usually  circular  and  slightly 
elevated,  averaging  2  to  5  mm.  in  size.  The  face  and  the  extensor 
surfaces  of  the  upper  and  lower  extremities  and  more  especially 
the  hands  and  feet  are  usually  involved  and  they  may  cover  the 
entire  body,  but  more  often  the  chest  and  abdomen  escape.  At 
first  red,  they  soon  become  darker  and  assume  a  coppery  hue. 
More  elevated  papules  similar  in  character  and  without  an  inflam- 
matory base  may  be  interspersed  among  the  macules.  A  squamous 
eruption  is  frequently  seen  upon  the  palms  and  soles  and  small 
masses  of  scales  may  appear  upon  the  surface  of  the  macules. 
The  eruption  may  develop  abruptly  but  more  frequently  it  increases 


LYMPH  GLANDS 


323 


progressively  during  a  period  of  from  one  to  three  weeks  and  under 
vigorous  treatment  disappears  rapidly  except  for  the  remaining 
pigmentation. 

In  the  most  severe  types  the  bullous  or  pemphigoid  lesions  may  be 
superimposed  upon  the  macular  squamous  syphilides  or  they  may 
be  primary.  They  may  lead  to  deeper  ulcerations  of  the  skin  with 
secondary  infection  and  are  always  a  source  of  danger  to  others 
because  of  the  likelihood  of  the  presence  of  spirochetes  in  the 
lesions.  The  possibility  of  the  confusion  of  these  lesions  with 
non-specific  pemphigoid  lesions  which  are  of  not  infrequent  occur- 
rence in  obstetrical  wards  should  be  remembered  as  the  latter  are 
especially  prone  to  affect  the  premature.  This  latter  type  of 
pemphigus  neonatorum  is  probably  a  staphylococcus  infection. 
Linear  fissures  and  mucous  patches  are  among  the  most  charac- 


i 

BlL'l^'»:"lfc                                                                 M 

•Wf^^F^  'mm 

.'  J 

*** 

_ 

- 

jpoi 

#4^ 

W***^ 

"*"■*-" 

Hp: 

Fig.  169. — Congenital  syphilis.     Baby  A.     Fissures  about  mouth.     Large  liver  and 
spleen.     Six  weeks  later. 

teristic  features.  On  account  of  the  fragility  of  the  skin  these 
rhagades  easily  occur,  especially  on  the  lips,  nose,  about  the  anus 
and  less  frequently  about  the  eyelids.  The  healing  of  these  lesions 
usually  results  in  radiating  cicatrices  which  result  in  the  very 
characteristic  "purse-string"  deformity. 

Umbilical  Cord.— The  umbilical  cord  often  heals  slowly  and  the 
stump  has  a  tendency  to  become  purulent  and  there  is  a  tendency 
toward  infiltration  about  the  umbilicus.  A  more  or  less  deep- 
seated  ulcer  may  result  which  heals  slowly  unless  constitutional 
treatment  is  instituted  or  mercurials  are  applied  locally.  Hemor- 
rhage from  the  stump  and  secondary  infection,  with  resulting 
syphilis  hemorrhagica  neonatorum  are  likely  to  result. 

Lymph  Glands.— Only  exceptionally  do  they  present  a  character- 
istic generalized  enlargement  in  the  new-born  syphilitic  premature. 


324 


SYPHILIS 


In  untreated  cases  the  lymph  glands  become  palpable  and  this  may 
be  due  to  luetic  infection  or,  again,  isolated  groups  of  glands  may 
become  involved  through  secondary  infection  and  go  on  to  suppu- 
ration. The  small  size  of  the  glands  makes  them  difficult  of  pal- 
pation, more  especially  in  well-nourished  infants. 


Fig.  170. — Osteochondritis  syphilitica. 


Osseous  System.— Osteochondritis  syphilitica  ranks  next  in 
importance  to  the  skin  and  mucous  membrane  lesions  and  splenic 
tumor  in  the  diagnosis  of  syphilis.  Pathological  changes  are  most 
frequently  seen  in  the  long  bones,  the  junction  of  the  epiphysis  with 
the  diaphysis  being  the  seat  of  predilection. 

These  lesions  are  usually  bilateral  although  occasionally  only  a 
single  lesion  can  be  defined  in  the  living.  Involvement  of  the 
joints  is  far  less  common.     While  the  long  cylindrical  bones  are 


OSSEOUS  SYSTEM  325 

the  seat  of  the  lesions  whieh  can  most  easily  be  defined  clinically, 
any  of  the  bones  may  be  the  seat  of  a  diffuse  involvement  of  the 
bony  structures  or  a  periostitis.  Such  lesions  are  more  commonly 
found  in  cases  resulting  in  early  fetal  death  (Fig.  170). 

Roentgenography  oilers  one  of  the  best  diagnostic  methods  for 
syphilis  in  the  fetus  and  new  born.  Shipley  and  his  co-workers1 
found  evidence  of  syphilis  in  the  osseous  system  of  25  per  cent 
of  100  white  fetuses  ranging  from  six  months  of  intra-uterine  life 
to  nearly  term.  Fifteen  of  these  showed  advanced  luetic  osteo- 
chondritis. The  bone  lesions  in  syphilitic  new-born  infants  present 
characteristic  lesions  when  there  is  sufficient  involvement  to  be 
evidenced  in  the  roentgenographic  plates.  While  any  of  the 
bones  may  suffer,  those  most  commonly  involved  and  easiest  of 
study  are  the  lower  end  of  the  femur,  upper  and  lower  ends  of  the 
tibia,  radius  and  ulna  and  the  metacarpals.  In  their  studies  they 
found  that  the  fetal  type  of  reaction  and  the  changes  before  birth 
were  to  a  large  extent  confined  to  the  epiphyseo-diaphyseal  region, 
at  which  points  there  develops  an  abnormal  arrangement  and 
distribution  of  osseous  tissue.  After  birth  the  periosteal  reaction 
begins,  possibly  because  of  the  increased  demands  made  on  this 
tissue  by  the  increased  muscular  activity,  and  in  young  infants 
this  may  be  the  most  marked  skeletal  lesion.  The  most  character- 
istic lesions  described  by  them  were  the  following: 

"The  beginning  of  the  process  as  shown  by  the  roentgen-ray 
picture  is  an  intensification  of  the  shadow  cast  by  the  bone  at  the 
epiphyseal  line.  This  line  becomes  much  broader  and  more  homo- 
geneous and  seems  to  form  a  cap  on  the  ends  of  the  trabecular  of 
the  spongiosa  (Fig.  172).  This  is  significant  of  the  beginning  of 
abnormally  heavy  calcification  of  the  provisional  calcified  zone.  It 
must  be  remembered  that  while  the  provisional  zone  of  calcification 
in  the  cartilage  of  the  normal  embryonic  bone  is,  relatively  speaking, 
very  narrow,  in  many  cases  only  one  or  two  cells  deep,  in  the 
syphilitic  bone  the  calcified  cartilage  may  show  on  section  a  width 
of  from  0.5  to  1.5  mm. 

"In  other  bones,  in  which  the  osteochondritis  is  further  advanced, 
it  can  be  seen  that  on  the  marrow  side  of  the  intensified  shadow 
of  the  provisional  zone  there  is  a  band-like  area  where  the  shadow 
is  less  intense  than  in  the  rest  of  the  bone  (Fig.  170),  giving  an 
appearance  of  diminished  density  to  the  region  of  the  epiphyseal 
line. 

"Bones  may  also  be  seen  in  which  the  dense  shadow  at  the  epiphy- 
seal end  of  the  bone  is  broken  by  the  presence  of  one  or  more  small 

1  Shipley,  P.  G.,  Pearson,  J.  W.,  Weech,  A.  A.,  and  Greene,  C.  H.:  Bull.  Johns 
Hopkins  Hosp.,  March,  1921,  p.  75. 


326 


SYPHILIS 


Fig.  171. — Hand  and  forearm  of 
human  fetus  to  show  extreme  excess- 
ive calcification  of  the  provisional  area 
with  irregular  prolongation  of  the  pro- 
visional calcified  zone  into  the  area  of 
proliferative  cartilage.  Note  the  pres- 
ence of  the  same  lesions  in  the  meta- 
carpals and  phalanges.     (Shipley.) 


Fig.  172. — Radius  and  ulna  from 
human  fetus  showing  beginning  re- 
sorption of  the  area  of  intense  calcifi- 
cation at  the  epiphyseo-diaphyseal 
junction.  Resorption  shown  by  areas 
of  decreased  density  of  shadow,  each 
resorptive  area  surrounding  a  small 
nucleus  of  persistent  trabecular  tissue. 
(Shipley.) 


Fig.  173. — Roentgen-ray  picture  of 
syphilitic  osteochondritis  of  the  bones 
of  the  hand  and  forearm  of  a  human 
fetus  showing  a  zone  of  rarefaction 
between  two  lines  of  abnormal  calci- 
fication. Note  the  lesion  in  the  pha- 
langes and  metacarpals.     (Shipley.) 


Fig.  174. — Syphilitic  periostitis  of 
both  bones  of  the  forearm.  Note  the 
longitudinal  striation  of  the  thick 
periosteal  shadow  which  is  nearly  in 
contact  with  the  shafts  of  the  bone. 
(Shipley.) 


OSSEOUS  SYSTEM  327 

areas  of  rarefaction  so  as  to  give  an  appearance  of  irregular  density 
to  the  end  of  the  bone  (Fig.  173). 

"At  other  times  the  bone  appears  to  end  in  a  double  line,  so  that 
two  lines  of  heavily  calcified  tissue  are  seen,  separated  each  from 
one  another  by  a  zone  in  which  lime  salts  are  less  heavily  deposited. 
This  zone  is  a  region  which  histological  preparations  show  to  con- 
tain a  great  deal  of  delicate  granulation  tissue.  This  picture 
becomes  more  and  more  intensified  as  growth  goes  on.  The  areas 
of  dense  shadow  and  the  fine  clearer  band  between  them  grow 
wider  and  the  surfaces  bounding  them  become  more  and  more 
irregular  and  jagged  until  the  end  of  the  bone  has  an  irregular 
appearance  (Fig.  171).     During  the  course  of  the  disease  the  calci- 


Fig.  175. — Distal  end  of  radius  and  ulna.  This  plate  shows  intense  calcification 
of  the  provisional  zone  with  resorption  areas  on  the  marrow  side  of  the  epiphyseal 
line.  Both  bones  show  syphilitic  periostitis  and  there  is  separation  of  the  cortex 
from  the  spongiosa  in  the  ulna.     (Shipley.) 

fication  of  the  infected  areas  is  not  only  abnormally  heavy  but  also 
most  irregular,  so  that  the  epiphyseal  border  of  the  shadow  cast  by 
the  bone  has  a  notched,  saw- toothed  or  serrated  appearance  (Fig. 
175). 

"Periostitis,  when  it  occurs  near  term  in  the  severe  cases  of  lues, 
may  be  present  throughout  the  length  of  the  bone  or  only  at  the 
extremities.  It  is  shown  in  roentgen-ray  plates  by  a  more  or  less 
wide,  almost  homogeneous,  shadow  or  with  longitudinal  striations 
separated  from  the  external  surface  of  the  cortex  by  a  narrow  clear 
area  which  bounds  the  bone  (Fig.  174). 

"One  other  feature  of  these  pictures  appears  worth  noting.  It 
may  be  seen  that  in  many  luetic  bones  the  cortex  is  separated  from 
the  spongiosa  by  a  very  narrow  clear  zone  winch  gives  the  cone 


328  SYPHILIS 

of  spongy  bone  the  appearance  of  being  suspended  unattached  within 
the  cortical  cavity  (Fig.  175).  In  the  roentgen-ray  picture  the 
trabecular  of  the  syphilitic  bone  appear  to  be  finer  than  those  of 
the  normal  bone. 

"Two  other  conditions  which  are  encountered  in  children  may 
give  roentgen-ray  pictures  which  closely  resemble,  and  in  some 
cases  are  identical  with,  the  pictures  described  above.  Scurvy 
and  rickets,  when  the  latter  disease  is  healing  under  the  influence 
of  cod-liver  oil  therapy,  may  be  difficult  or  impossible  to  differ- 
entiate by  roentgenographic  means  from  osteal  syphilis  of  the 
fetal  type.  Fortunately,  however,  in  the  early  weeks  of  life  neither 
of  these  conditions  need  be  seriously  considered  in  diagnosticating 
hereditary  lues,  since  there  is  no  good  evidence  to  show  that  fetal 
rickets  ever  occurs  and  it  is  agreed  that  scorbutus  is  rare  before 
the  sixth  month  of  life  has  been  reached." 

Liver.— It  may  be  stated  that  not  less  than  50  per  cent  of  pre- 
maturely born,  syphilitic  infants  show  a  distinct  enlargement  of 
the  liver.  A  fair  percentage  of  the  cases  show  a  marked  increase 
in  size  and  consistency  to  such  an  extent  that  the  abdominal  dis- 
tention in  its  upper  half  is  visible  to  the  naked  eye.  These  latter 
cases  are  usually  associated  with  marked  jaundice,  dilated  veins 
and  an  impairment  of  hepatic  function  and  a  high  mortality. 
Because  of  the  relatively  large  liver  of  the  premature  new  born 
normally  present,  difficulty  may  be  experienced  in  the  diagnosis 
of  a  moderate  increase  in  size  due  to  syphilis.  It  is  also  to  be 
remembered  that  many  other  factors  predisposing  to  premature 
birth  have  a  direct  influence  on  the  size  of  the  liver.  The  char- 
acteristic pathological  findings  are  interstitial  infiltration  of  the 
connective  tissues  between  the  acini  and  about  the  vessels.  Small 
gummata,  often  the  seat  of  central  necrosis  are  more  exceptionally 
found.  The  frequent  involvement  of  the  liver  is  readily  explained 
by  the  peculiarity  of  the  fetal  circulation.  The  placental  blood 
passing  through  the  portal  circulation  by  way  of  the  umbilical 
veins,  conveys  the  spirochetes  into  the  liver  substance. 

Spleen.— Enlargement  of  the  spleen,  while  usually  moderate,  is 
one  of  the  most  important  confirmatory  signs  but  is  in  itself  of 
lesser  diagnostic  importance  than  the  skin  and  'mucous  membrane 
lesions.  An  easily  palpable  and  hard  splenic  tumor  in  the  first 
three  months  of  life,  that  is,  before  the  advent  of  rickets  in  the 
premature,  should  always  be  looked  upon  with  suspicion.  The 
enlargement  is  usually  due  to  hyperplasia  of  the  pulp,  with  occa- 
sional presence  of  foci  of  myeloid  cells.  Cellular  infiltration  of 
the  interstitial  tissue  may  be  present. 

Respiratory  System.  —The  lesions  of  the  nasal  mucous  membranes 
have  been   described.     Frequently   there  is  a   chronic  catarrhal 


KIDNEYS  329 

laryngitis  and  perichondritis,  with  involvement  of  the  epiglottis. 
In  the  fetus  and  in  infants  dying  soon  after  birth  the  so-called 
"pneumonia  alba"  or  "white  pneumonia"  is  often  present.  In 
these  cases  a  considerable  portion  of  the  pulmonary  tissue  appears 
whitish-gray,  airless  and  smooth  on  section,  due  to  cellular  infiltra- 
tion of  the  interstitial  tissue,  filling  of  the  alveoli  and  bronchi  with 
degenerated  epithelium  and  proliferation  of  the  intima  of  the 
vessel  walls.  Not  infrequently  the  pleura  is  the  seat  of  small 
gumma-like  nodular  infiltrations.  Massive  involvement  of  the 
lungs  is  rarely  compatible  with  life.  Because  of  their  lowered 
vitality,  syphilitic  infants  are  subject  to  secondary  bronchial  and 
pulmonary  infection,  pneumonia  being  a  frequent  cause  of  death. 

Circulatory  System.— Most  characteristic  lesions  are  found  in  the 
small  bloodvessels  and  careful  examination  shows  the  presence  of 
spirochetes  in  the  vessel  walls.  These  findings  are  most  easily 
demonstrated  in  the  parenchymatous  organs.  The  characteristic 
lesions  following  such  involvement  are  those  of  coagulation  necrosis, 
with  secondary  hemorrhages,  following  rupture  of  the  vessel  walls. 
These  lesions  may  result  in  more  or  less  generalized  or  local  hemor- 
rhagic skin  lesions  and  those  from  the  various  mucous  membranes. 
Intracranial  lesions  frequently  result  from  degeneration  of  the 
bloodvessels,  even  in  the  absence  of  trauma. 

Digestive  System.— Chronic  catarrhal  pharyngitis  is  a  common 
early  symptom  which  may  later  be  followed  by  ulcerations  of  the 
pharynx,  tonsils  and  fauces.  Only  rarely  is  the  stomach  involved 
and  the  lesions  of  the  intestines  which  are  also  infrequent  are 
usually  seen  as  hyperplasia  of  the  solitary  follicles  and  Peyer's 
patches  which  may  become  necrotic  and  result  in  hemorrhages. 
Scattered  areas  of  necrosis  not  associated  with  the  lymphoid  tissue, 
but  due  directly  to  bloodvessel  degeneration  may  be  found  through- 
out the  intestines.  Peritonitis  is  a  more  frequent  finding  in  the 
still  born  than  in  viable  infants.  It  may  be  of  the  acute  type 
but  in  most  instances  it  is  of  the  chronic  type  and  may  result  in 
formation  of  adhesions.  Localized  or  generalized  ascites  may 
result. 

The  pancreas,  thymus  gland,  suprarenal  bodies  and  thyroid  gland 
occasionally  exhibit  interstitial  inflammation,  gummata  or  other 
syphilitic  manifestations.  Small  cystic  formations  are  frequently 
found  in  the  thymus  gland,  usually  varying  in  size  from  1  to  5  mm. 
It  is  a  question  whether  they  are  due  to  arrest  of  development  or 
necrosis.  Purulent  material  with  which  they  are  filled  contains 
spirochetes. 

Kidneys.— While  all  types  of  nephritis  have  been  described,  those 
of  greatest  importance  are  the  interstitial  and  hemorrhagic.  Inter- 
stitial nephritis  is  a  serious  complication  because  of  the  danger  of 


330  SYPHILIS 

late  secondary  contraction.  It  is  frequently  overlooked  because 
of  the  absence  of  marked  urinary  findings.  The  hemorrhagic  types 
are  usually  associated  with  hemorrhages  from  some  of  the  other 
mucous  membranes.  The  dangers  of  overmedication  with  arsenic 
and  mercury  preparations,  in  the  presence  of  kidney  lesions  must 
not  be  overlooked.  Hecker1  states  that  he  has  been  able  to  demon- 
strate microscopical  changes  in  90  per  cent  of  his  autopsies. 

Nervous  System.— Involvement  of  the  brain  and  its  meninges  is 
more  frequent  than  that  of  the  cord.  The  most  frequent  lesions  in 
the  still  born  and  those  dying  shortly  after  birth  is  a  meningo- 
encephalitis, involving  the  pia  and  cortex.  The  pia  is  infiltrated 
and  covered  by  an  exudate  composed  of  plasma  cells  and  lympho- 
cytes. Similar  areas  are  seen  in  the  cortex  and  the  medulla  may 
be  involved.  The  most  frequent  lesion  in  viable  infants  is  a  men- 
ingitis serosa  interna  and  externa,  which  is  not  usually  noted 
until  after  the  first  few  weeks  of  life.  It  may  develop  acutely  or 
insidiously  and  usually  results  in  a  more  or  less  marked  hydro- 
cephalus. Because  of  the  late  development  in  some  infants  and 
the  early  appearance  of  rickets  in  the  premature  it  should  not  be 
confused  with  megacephalus  so  commonly  seen  in  the  latter. 
Pachymeningitis  hemorrhagica  less  frequently  seen  than  the  former, 
usually  develops  after  the  first  few  weeks  of  life.  Intracranial 
hemorrhages  are  probably  a  more  frequent  cause  of  extra-uterine 
death  than  is  commonly  supposed.  Gummatous  meningitis  and 
ependymitis  are  among  the  rare  lesions.  Increased  intracranial 
pressure,  as  evidenced  by  increased  tension  over  the  fontanelles,  and 
which  is  usually  accompanied  by  hyperexcitability  on  the  part  of 
the  infant,  should  lead  to  a  lumbar  puncture  for  diagnostic  purposes. 
Increased  pressure  and  an  increase  in  the  number  of  lymphocytes 
in  the  spinal  fluid  are  always  suggestive  but  not  positive  evidence. 
A  Wassermann  and  Lange  reaction  when  positive  may  usually  be 
considered  as  conclusive  evidence.  When  these  reactions  are 
negative,  in  the  presence  of  other  positive  signs,  a  careful  search 
should  be  made  for  spirochetes. 

Any  of  the  lesions  of  the  central  nervous  system  may  result  in 
retarded  mental  and  physical  development. 

Eyes.— The  most  frequent  lesions  are  choroiditis,  optic  neuritis, 
iritis  and  parenchymatous  keratitis.  They  are  of  frequent  occur- 
rence in  the  still  born  and  may  develop  in  the  first  weeks  of  life. 

Ears.— The  organs  of  hearing  are  occasionally  involved  by  lesions 
which  may  be  described  as  specific.  The  most  common  is  an 
involvement  of  the  eighth  nerve.     Involvement  of  the  organs  of 

1  Beitrag  zur  Histologie  and  Pathologie  der  kongenitalen  Syphilis  sowie  zur  norm- 
alen  Anatomie  des  Fotus  und  neugeborenen,  Deutsch.  Arch.  f.  klin.  Med.,  1898,  61,  1. 


LABORATORY  DIAGNOSIS  331 

the  internal  ear  early  in  life  is  difficult  of  proof.  Otitis  media  as 
usually  seen  is  due  to  a  secondary  infection. 

Laboratory  Diagnosis.— "Whenever  there  is  a  suspicion  of  the 
presence  of  syphilis  during  pregnancy  the  blood  of  both  parents 
should  be  examined  so  as  to  give  both  the  mother  and  fetus  the 
benefit  of  treatment.     This  will  be  given  further  consideration. 

In  cases  in  which  the  diagnosis  has  not  been  made  before  labor 
and  the  possibility  of  syphilis  exists  the  placenta  should  be  examined 
histologically  and  the  placental  cord  blood  should  be  examined  for  a 
Wassermann  reaction.  It  is  estimated  that  about  50  per  cent  of 
placenta?  will  show  more  or  less  diffuse  lesions  upon  microscopical 
examination.  Jeans  and  Cooke1  found  that  57  per  cent  of  their 
syphilitic  infants  gave  a  positive  Wassermann  reaction  on  their 
cord  blood.  They  found  that  in  every  instance  in  which  the 
placenta  was  noted  as  showing  syphilitic  changes  the  infant  was 
later  found  to  have  syphilis.  While  a  positive  Wassermann  reaction 
may  be  regarded  as  nearly  specific,  a  negative  reaction  must  not  be 
regarded  as  indicating  an  absence  of  the  disease  when  made  during 
the  first  days  or  weeks  of  life,  as  a  large  group  of  infants  show  little 
or  no  tendency  to  give  a  positive  Wassermann  before  the  end  of  the 
second  month  of  life.  In  fact,  some  of  them  do  not  react  before 
the  end  of  the  third  or  fourth  month.  Negative  findings  in  the 
presence  of  lesions  or  suspicion  of  infection  on  the  part  of  the 
mother  should,  therefore,  lead  to  an  examination  of  maternal  and 
paternal  blood.  The  variability  in  the  reaction  of  a  new  born  to 
the  Wassermann  test  is  best  evidenced  by  the  report  of  one  positive 
and  one  negative  reaction  in  each  of  a  pair  of  twins  by  DeBuys2 
and  Gerstenberger.3 

The  blood  taken  from  the  infant  during  the  first  week  or  two  of 
life  shows  a  somewhat  higher  average  of  positive  serum  reaction 
than  examination  of  placental  blood  taken  from  the  same  cases. 
In  the  premature  the  blood  can  be  taken  from  the  longitudinal 
sinus,  a  scalp  vein  or  by  a  small  incision  in  the  heel.  The  applica- 
tion of  the  luetin  test  offers  serious  objection  in  premature  infants, 
because  of  danger  of  secondary  infection.  In  full-term  infants 
it  averages  a  higher  percentage  of  positives  than  the  Wassermann. 

Demonstration  of  spirochetes  in  the  open  skin  lesions  and  bulla? 
as  well  as  from  the  scraping  of  the  mucous  membrane  ulcerations, 
makes  the  diagnosis  absolute  when  the  Treponema  pallidum  is 
found. 

While  spinal  and  ventricular  punctures  are  to  be  avoided  when 
possible  in  premature  infants,  examination  of  the  cerebrospinal  fluid 

1  Trans.  Am.  Pediat.  Soc,  1920,  vol.  32. 

2  Jour.  Obst.  and  Dis.  Women  and  Child.,  January,  1913,  p.  65. 

3  Personal  communication. 


332  SYPHILIS 

may  be  necessary  when  other  findings  are  negative  in  the  presence  of 
possible  clinical  nervous-system  syphilis.  About  25  per  cent  of 
new-born  infants  will  show  spinal  fluid  changes  of  sufficient  import- 
ance to  have  a  diagnostic  value.  These  changes  consist  of  a  positive 
Wassermann,  which  when  present,  is  usually  associated  with  a 
definite  albumin  and  globulin  increase.  More  often  the  cell  count 
reveals  a  moderate  pleocytosis. 

Prophylaxis.— It  is  almost  needless  to  say  that  luetic  individuals 
should  not  be  permitted  to  marry.  With  the  improved  methods 
of  laboratory  diagnosis  of  today— luetin,  Lange  and  Wassermann 
tests— it  is  now  possible  in  a  relatively  high  percentage  of  cases  to 
discover  if  an  individual  has  a  latent  or  active  syphilis.  When 
there  is  the  slightest  suspicion  of  a  specific  infection  during  preg- 
nancy, the  mother  should  be  treated  intensively.  This  offers  the 
only  hope  of  preventing  a  similar  infection  of  the  infant  with  its 
consequences,  or  of  ameliorating  the  condition.  It  is  noteworthy 
that  women  with  luetic  histories  do  much  better  if  under  treatment 
during  pregnancy,  so  that  prematurity  and  still  birth  may  often 
be  avoided.  In  the  absence  of  specific  therapy  the  child,  instead 
of  being  born  healthy,  may  show  active  syphilitic  manifestations 
or  develop  them  later. 

As  in  the  prophylaxis  of  any  infection  of  infancy,  extreme  care 
must  be  exercised  with  reference  to  the  sterilization  of  feeding  and 
bathing  utensils  and  clothing. 

Nursing. — Whenever  a  mother  bears  an  infant  evidencing  lues, 
if  she  is  at  all  able,  she  should  nurse  her  infant.  It  seems  well 
established  today  that  the  mother  is  syphilitic,  whether  or  not  her 
history  is  positive,  and  even  in  the  absence  of  clinical  manifestations. 
The  older  controversies  as  to  the  possibility  of  infection  of  the 
mother  by  the  child  and  vice  versa  consequently  do  not  enter  into 
consideration.  Where  an  adequate  supply  of  milk  is  present  it  is 
of  the  utmost  importance  that  the  premature  infant  be  suckled. 
If  the  mother  objects  to  nursing  her  infant  at  the  breast  because 
of  nasal  and  mouth  lesions  a  shield  may  be  used  or  the  milk  expressed 
and  hand  fed. 

Where  the  mother  is  unable  to  nurse  her  child  a  wet-nurse  should 
not  be  employed  to  suckle  the  child  at  her  own  breasts  because 
of  the  obvious  danger  of  infection  of  the  nurse.  Expressed  milk  is, 
of  course  very  desirable. 

Active  Treatment.— In  syphilis  neonatorum,  which  so  fre- 
quently is  associated  with  serious  visceral  changes  and  so  commonly 
affects  children  born  prematurely,  the  prognosis  is  in  general  serious. 
Very  commonly  the  infants  with  serious  forms  of  pemphigus,  even 
with  early  instituted  treatment  and  with  human  milk  feedings,  die 
in  the  first  days  or  weeks  of  life.  An  essentially  better  prog- 
nosis is  offered  by  the  cases  with  maculo-papular  or  papulo-bullous 


ACTIVE  TREATMENT  333 

syphilides  provided  always  that  the  internal  organs  are  not  seriously 
damaged. 

As  soon  as  the  diagnosis  is  made  certain,  antiluetic  treatment 
should  be  immediately  instituted.  Healthy  infants  and  those  free 
from  symptoms  but  born  from  luetic  parents  should  be  treated 
prophylactically. 

Certain  facts  already  enumerated  in  the  general  care  of  premature 
infants  should  be  especially  emphasized  in  the  care  of  this  same 
class  of  infants  born  of  syphilitic  parents,  even  though  they  show 
no  manifestations  at  the  time  of  their  birth.  Practically  all  of  them 
show  more  or  less  evidence  of  malnutrition  and,  therefore,  in  this 
class  of  infants,  as  in  no  other,  is  breast-feeding  indicated.  Every 
effort  should  be  made  to  stimulate  the  breast-milk  supply  on  the 
part  of  the  mother  because  of  the  difficulty  encountered  in  obtain- 
ing a  sufficient  supply  from  other  sources,  as  well  as  the  danger  to 
a  healthy  wet-nurse. 

In  the  presence  of  a  syphilitic  history  or  positive  laboratory 
findings  in  the  parents,  or  the  findings  of  clinical  manifestations 
in  the  infant  a  vigorous  course  of  treatment  should  be  instituted 
without  regard  to  the  presence  or  absence  of  a  Wassermann  reac- 
tion. In  every  case  in  which  treatment  is  instituted  the  fetal  age 
and  general  condition  of  the  infant  must  be  taken  into  consideration 
and  the  effect  of  medication,  whether  mercurial  or  arsenic  prepara- 
tions, carefully  noted.  Early  dosage  with  each  form  of  medication 
should,  therefore,  be  small,  however,  maximum  administration  for 
the  given  infant  should  be  attained  as  early  as  possible. 

Mercury  Therapy. — Three  routes  of  administration  deserve  con- 
sideration:   Oral,  external  and  intravenous. 

In  the  treatment  of  older  infants  and  children  many  clinicians 
of  large  experience  advocate  the  use  of  the  arsenic  preparations  as 
of  first  importance  and  while  mercurial  preparations  are  considered 
as  absolutely  necessary  to  effect  a  cure,  they  are  given  a  secondary 
place.  In  view  of  this  tendency  it  is  well  that  we  recall  our  earlier 
good  results  in  the  treatment  of  congenital  syphilis  before  the 
discovery  of  these  newer  preparations.  It  is  our  belief  that  mercury 
should  rank  first  in  the  treatment  of  syphilis  in  the  premature  and 
that  arsenic  therapy  should  rank  second  in  importance:  (1)  Because 
of  the  lesser  danger,  and  (2)  because  of  the  rapid  improvement  which 
may  be  expected  in  a  large  majority  of  the  cases.  However,  the 
dangers  of  overmedication,  both  by  mouth  and  injection  with 
mercury  must  also  not  be  overlooked.  These  are  usually  evidenced 
by  a  lack  of  progress  on  the  part  of  the  infant,  diarrhea  and  evi- 
dences of  hepatitis  and  nephritis. 

For  internal  use  the  favorite  preparations  are  hydrargyrum  cum 
creta,  0.005  to  0.03  gm.  (yV  to  \  gr.),  or  hydrargyrum  iodidum 
flavum  in  doses  of  0.002  to  0.005  gm.  (^  toyo  gr.)  three  times  daily. 


334  SYPHILIS 

It  is  well  to  begin  with  small  doses,  preferably  of  the  former  and 
increase  rapidly  to  the  maximum  dose  in  the  absence  of  diarrhea. 
In  the  presence  of  diarrhea  the  dose  should  be  reduced.  The  intra- 
muscular treatment  must  be  administered  with  even  greater  fore-, 
thought.  For  this  purpose  0.0005  gm.  (T^  gr.)  of  bichloride  in 
0.2  cm.  (3  mm.)  of  distilled  water  or  oil,  for  each  kilogram  of  body 
weight  (2-ij-  pounds)  are  recommended.  The  injections  are  to  be 
given  once  or  twice  weekly  and  should  be  made  deep  into  the 
muscle.  The  gluteal  muscles  offer  one  of  the  best  sites  for  injections. 
The  skin  surface  should  be  sterilized  with  a  not  too  concentrated 
tincture  of  iodine  and  the  injection  is  made  deep  into  the  muscle 
by  the  use  of  a  short  needle,  preferably  of  about  a  20  gauge  (for 
oil)  and  \  to  f  inch  in  length.  Care  should  be  used  so  that  none  will 
be  deposited  in  the  subcutaneous  tissues.  A  course  of  four  to  eight 
injections,  covering  a  period  of  four  weeks,  is  recommended,  these 
to  be  followed  by  a  rest  period  of  four  weeks,  during  which  arsenic 
injections  are  given.  The  oral  administration  of  mercury  should 
be  continued  throughout  this  period.  Sublimate  baths  may  be 
successfully  used  in  all  moist  forms,  especially  in  all  exanthemata 
associated  with  vesicle  formation— 0.2  gm.  (3  gr.)  for  a  bath  of 
about  4  liters  (1  gallon)  of  water. 

Inunctions  are  applicable  in  infants  in  whom  the  skin  is  not  too 
sensitive  and  are  one  of  the  best  forms  of  treatment.  In  the  presence 
of  local  skin  irritation  it  becomes  necessary  to  stop  this  form  of 
treatment.  The  clanger  of  overmedication  with  mercury  must, 
however,  be  borne  in  mind.  Mercurial  ointment  is  especially 
valuable  for  local  application  to  ulcerated  lesions  and  may  be 
applied  to  the  deeper  seated  lesions  of  the  hands  and  feet  by  the 
use  of  mittens  and  stockings.  For  these  purposes  the  official 
mercurial  ointment  should  be  mixed  with  2  parts  of  lanolin.  In 
the  more  mature  infants  it  should  be  carefully  rubbed  into  the 
abdominal  wall,  axillse  or  thighs  and  the  same  site  used  only  at 
infrequent  intervals  in  order  that  cutaneous  irritation  be  avoided. 
For  a  local  lesion  2  per  cent  of  yellow  oxide  of  mercury  ointment 
will  do.  In  the  presence  of  snuffles  a  1  per  cent  yellow  oxide  of  mer- 
cury ointment  should  be  used.  The  ointment  is  introduced  into 
each  nostril  directly  from  a  small  compressible  tube.  It  may  be 
necessary  to  carefully  remove  any  excessive  secretions  with  a  pledget 
of  cotton  or  by  washing  with  a  normal  salt  solution  before  applying 
the  ointment. 

It  is  advisable  to  continue  mercurial  treatment  for  at  least  a  year, 
decreasing  the  dose  in  the  second  six  months,  and  repeating  three 
months  of  such  therapy  during  the  second  and  third  years,  even  in 
the  absence  of  symptoms.  As  in  treating  older  infants,  there  should 
be  short  periods  when  treatment  is  discontinued. 


ACTIVE  TREATMENT  335 

Arsenic  Thera/py.—lt  is  indicated  in  most  cases  as  an  adjunct 
to  mercurial  treatment.  Neoarsphenamine  is  the  preparation  of 
choice  for  use  with  the  premature  because  of  the  fact  that  it  can 
he  administered  in  more  concentrated  solution,  its  greater  solu- 
bility and  the  lack  of  necessity  for  neutralization.  It  can  be 
administered  intravenously  in  water  or  by  intramuscular  injections 
in  a  bland  oil. 

The  average  dose  is  0.01  gm.  for  each  kilogram  of  body  weight. 
The  dose  should  be  diluted  with  2  cc  of  sterile,  freshly  distilled 
water  for  intravenous  use.  It  is  advisable  to  give  one-half  of  this 
quantity  per  kilogram  for  the  first  treatment.  A  course  of  four 
intramuscular,  or,  when  possible,  preferably  intravenous  injections 
are  given  at  weekly  intervals  to  be  followed  by  a  rest  period  of  four 
weeks  when  the  treatment  is  to  be  repeated.  During  the  period 
of  administration  of  neoarsphenamine  the  mercurial  injections 
should  be  discontinued  but  the  oral  administration  continued. 

Complications  following  the  intramuscular  injection  of  neo- 
arsphenamine, such  as  abscesses  and  infiltrations  can,  to  a  large 
degree,  be  avoided  by  the  use  of  special  needles,  which  permit  the 
solution  to  be  injected  deep  into  the  muscle.  After  injection,  the 
needle  is  rapidly  withdrawn  and  a  cotton  pledget  is  pressed  firmly 
over  the  site  of  injection  for  a  few  minutes. 

For  intravenous  administration  the  best  sites  are  scalp  veins 
or  the  external  jugular  vein.  For  administration  into  the  latter 
site  the  infant  should  lie  with  the  shoulders  elevated  and  the  head 
extended  and  rotated.  Only  in  very  exceptional  cases  should 
cutting  down  on  a  vein  be  practised.  The  longitudinal  sinus  route 
for  arsenic  injection  is  not  to  be  considered  because  of  the  danger 
of  passing  through  the  sinus  and  extravasating  the  preparation  over 
the  brain  tissue. 

The  general  plan  of  treatment  should,  therefore,  be  as  follows: 
One  of  the  mercury  preparations  should  be  administered  in  suitable 
doses  three  times  daily  per  mouth,  and  once  or  twice  weekly  during 
the  first  four  weeks  an  intramuscular  injection  of  one  of  the  mercurial 
preparations  should  be  given.  During  the  second  month  the  oral 
administration  should  be  continued  but  the  mercurial  injection 
should  be  replaced  by  neoarsphenamine,  preferably  intravenously, 
once  each  week.  Mercurial  ointment  as  inunctions  or  local  appli- 
cations are  to  be  used  when  indicated. 

This  plan  of  treatment  should  be  continued  throughout  the  first 
year,  in  the  absence  of  toxic  symptoms  and  at  least  three  months 
of  treatment  should  be  given  during  the  second  and  third  years. 
Treatment  should  be  continued  for  at  least  six  months  after  all 
evidence  of  activity  has  disappeared.  This  includes  a  negative 
Wassermann.  At  no  time  should  a  negative  Wassermann  in  early 
infancy  be  considered  as  sufficient  evidence  to  interfere  with  the 
general  course  of  treatment  as  outlined. 


CHAPTER  XVI. 
TUBERCULOSIS  IN  PREMATURES. 

The  recorded  cases  of  tuberculous  affections  during  the  first  weeks 
of  life  are  unusually  rare,  and  their  clinical  symptoms,  even  when 
anatomically  demonstrable  changes  are  present,  ordinarily  are 
not  to  any  extent  characteristic.  While  in  comparison  with  the 
acquired  tuberculosis,  the  congenital  form  is  almost  a  rarity, 
nevertheless  numerous  authentic  instances  are  on  record. 

M.  Pehu  and  J.  Chalier1  have  collected  51  cases  from  the  litera- 
ture, the  authenticity  of  which  has  been  established.  While  some 
of  these  cases  have  resulted  in  premature  birth,  the  majority  have 
been  born  at  full  term;  and  although  some  of  the  latter  have  been 
well  developed,  most  of  them  have  suffered  from  congenital  debility. 

Planchu  and  Devin2  describe  39  premature  infants  born  of 
tuberculous  mothers.  They  believe  that  the  morbidity  and 
mortality  is  greater  in  infants  born  prematurely  from  tuberculous 
mothers  than  the  average  for  those  born  prematurely  of  other 
causes. 

While  infants  born  at  full  term  of  tuberculous  mothers  may 
occasionally  be  well  developed,  the  majority  nevertheless,  if  infected 
with  tuberculosis  before  leaving  the  uterine  cavity,  show  marked 
congenital  debility.  As  a  case  in  point  in  evidence  for  the  possi- 
bility of  good  development,  may  be  cited  the  infant  of  H.  Rollet,3 
which  died  forty-eight  hours  after  birth,  but  in  whom  large  caseous 
areas  were  found  in  the  bronchial  glands,  lungs,  liver  and  spleen. 
The  mother  of  this  child  died  eighteen  days  post  partum  from 
miliary  tuberculosis,  and  on  examination  it  was  found  that  the 
uterus  still  contained  placental  remnants  from  which  numerous 
tubercle  bacilli  were  obtained. 

In  cases  of  intra-uterine  infection  the  tubercle  bacilli  penetrate 
into  the  body  of  the  infant,  either  by  way  of  the  placental  blood 
or  by  the  swallowing  of  liquor  amnii.  It  is  impossible  for  the 
embryo  to  become  infected  unless  the  mother  be  tuberculous. 

The  transmission  of  the  bacilli  from  the  mother  to  the  infant 


1  Heredity  in  Tuberculosis,  Arch,  de  med.  des  enf.,  1915,  18,  1. 

2  Le  Premature  de  Mere  tuberculeuse,  Lyon  rned.,  1911,  116,  72. 

3  Ueber  intra-uterine  miliare  tuberculose,  Wien.  klin.  Wchnschr.,  1913,  No.  31, 
26,  1274-1275. 


TUBERCULOSIS  IN  PREMATURES  337 

can  occur  at  any  time  during  pregnancy.  This  may  result  from 
bacilli  carried  in  the  fetal  circulation,  from  various  parts  of  the 
mother's  body,  or  through  organisms  found  in  placental  lesions. 
The  normal  placenta  is  usually  conceived  to  be  a  filter  impermeable 
to  bacteria.  Presumption  for  the  passage  of  tubercle  bacilli  from 
the  blood  of  the  mother  to  that  of  the  infant  is  a  lesion  of  this  filter. 
Tubercle  bacilli  can  pass  into  the  blood  stream  of  the  infant  only 
when  a  communication  has  been  established  between  the  inter- 
villous spaces  and  the  bloodvessels  of  the  chorionic  villi,  or  when 
liquor  amnii  becomes  infected  with  the  organisms.  Therefore,  the 
bacilli  infecting  the  fetus  must  come  either  from  a  tuberculous 
placenta  or  from  the  circulating  blood.  The  transmission  of 
bacilli  into  the  blood  of  the  infant  takes  place  when  a  bloodvessel 
of  the  villus  becomes  eroded  or  ruptured. 

Tuberculous  changes  in  the  decidua  vera  or  in  the  chorionic 
covering  of  the  placenta  may  result  in  infection  of  the  liquor  amnii 
by  breaking  through  the  amnion,  and  also  in  intestinal  infection 
with  eventual  general  systemic  distribution. 

The  intra-uterine  infections  above  described  may  lead  to  advanced 
tuberculous  processes  at  birth.  Such  infants  are  usually  born 
premature  or  show  great  debility.  Not  infrequently  the  infant  is 
infected  through  the  transmission  of  the  organisms  during  birth, 
when  in  the  separation  of  the  placenta  the  bloodvessels  of  the  villi 
become  ruptured,  and  thereby  passage  to  the  blood  of  the  infant, 
either  from  the  tuberculous  foci  of  the  placenta,  or  from  the  maternal 
blood,  is  made  possible.  In  these  latter  cases  no  specific  changes 
are  found  in  the  organs  at  birth,  and  these  infants  are  likely  to 
be  well  developed. 

Intrapartum  infection  may  take  place  through  swallowing 
or  more  rarely  through  inhalation  during  the  passage  of  the  child 
through  the  birth  canal. 

The  infection  may  take  place  after  birth  (acquired  tuberculosis) . 
This  occurs  either  by  way  of  the  respiratory  tract  through  inhala- 
tion, or  by  way  of  the  digestive  tract,  or  through  other  portals  of 
entrance,  far  less  common. 

It  is  of  the  greatest  importance  from  the  clinical  point  of  view 
to  separate  the  infants  who  are  born  with  tuberculous  organic 
changes  from  those  who  are  born  without  such  pathology.  The 
new-born  infant  in  this  situation  is  in  the  stage  of  incubation  for 
tuberculosis. 

Unfortunately  such  clinical  distinction  is  usually  impossible 
because  of  the  absence  of  pathognomonic  symptoms,  and  the 
failure  of  specific  tests  during  the  first  weeks  of  life.  While  the 
cutaneous  and  intracutaneous  reactions  are  rarely  seen  before  the 
fourth  week  of  life,  a  few  cases  have  been  described.  Among  these 
22 


338  TUBERCULOSIS  IN  PREMATURES 

is  that  of  Zarlf,1  who  reported  a  positive  von  Pirquet  reaction  in 
a  seventeen-day  old  infant,  which  was  still  living  at  the  time  of  the 
report,  six  weeks  after  birth.  In  the  discussion  of  this  case  von 
Pirquet  remarked  that  this  was  the  earliest  age  at  which  a  positive 
reaction  had  been  reported  to  his  knowledge,  and  that  he  believed 
it  to  be  proof  of  the  congenital  origin  of  the  case,  as  his  conception 
was  that  at  least  four  weeks  must  pass  after  the  time  of  infection 
before  a  positive  tuberculin  reaction  may  be  obtained. 

It  should  be  remembered  that  prematurity  and  congenital 
debility  on  the  part  of  infants  born  of  tuberculous  mothers  does 
not  necessarily  mean  that  the  child  is  suffering  either  from  congenital 
or  hereditary  tuberculosis.  It  should  not  be  forgotten  that  infants 
infected  with  tuberculosis,  in  whom  there  are  only  minor  or  no 
tuberculous  lesions,  may  be  born  at  full  term,  seemingly  robust. 

Etiology.— The  frequency  of  tuberculosis  as  an  etiological  factor  in 
premature  births  or  general  debility  of  full -term  infants  must  be  con- 
sidered: (1)  From  the  standpoint  of  the  effect  of  tuberculosis  on 
the  entire  organism  of  the  mother;  (2)  its  influence  on  the  genera- 
tive organs  of  the  mother;  (3)  its  effect  on  the  general  development 
of  the  fetus;  (4)  of  a  systemic  infection  of  the  fetus;  (5)  from  the 
viewpoint  of  the  results  as  they  affect  the  future  development  of  the 
infant,  which  may  be  born  at  full  term,  without  manifest  evidence 
of  congenital  debility. 

1.  Effect  of  Tuberculosis  on  the  Entire  Organism  of  the  Mother. — 
While  numerous  authentic  cases  of  congenital  tuberculosis  are  now 
on  record,  by  far  the  majority  of  infants  born  of  tuberculous  mothers 
do  not  show  evidence  of  systemic  tuberculosis  at  autopsy,  and  in 
our  own  studies  of  such  instances  in  the  Cook  County  Hospital  over 
a  period  of  several  years,  the  only  well-authenticated  case  which 
has  come  under  observation  and  which  has  proven  to  be  one  of 
general  tuberculosis  on  the  part  of  the  infant,  was  reported  by 
Grulee.2  The  infant  died  on  the  eleventh  day  after  its  birth,  and 
at  autopsy  showed  a  generalized  tuberculosis,  affecting  most 
markedly  the  abdominal  organs  and  especially  the  periportal 
lymph  glands,  liver  and  spleen.  The  tuberculosis  was  miliary  in 
type,  but  the  stage  of  the  tubercles  suggested  an  intra-uterine  infec- 
tion. The  mother  was  still  living  several  months  after  the  infant's 
death. 

In  contradistinction  to  this  case  we  have  had  occasion  to  observe 
numerous  instances  in  which  infants  born  of  tuberculous  mothers 
have  survived,  and  have  either  progressed  more  or  less  normally,  or 
have  died  of  infections  other  than  tuberculosis— in  whom  at  least 
tuberculosis  could  not  be  demonstrated  at  autopsy. 

1  Congenital  Tuberculosis,  Jahrb.  f.  Kinderh.,  1913,  No.  1,  67,  95. 

3  Tuberculosis  as  a  Disease  of  the  New  Born,  Am,  Jour.  Dis,  Child.,  1915,  9,  322. 


ETIOLOGY  339 

2.  Effect  on  the  Generative  Organs'  of  the  Mother.  — Tuberculosis 
can  be  transmitted  through  the  uterus,  either  through  local  lesions 
or  without  demonstrable  lesions  in  the  uterus  and  placenta. 
G.  Luenherger1  contributes  records  of  two  interesting  cases  of  pla- 
cental and  congenital  tuberculosis,  which  illustrate  the  abo  Yemen  - 
tioned  possibilities.  In  the  first  instance  the  mother  died  of  tubercu- 
lous meningitis  and  miliary  tuberculosis.  Tubercle  bacilli  were  found 
in  the  fetal  liver  and  numerous  miliary  tubercles  in  the  placenta. 
Injection  of  a  small  piece  of  liver  extract  and  of  the  heart's  blood 
of  the  fetus  into  a  guinea-pig  gave  rise  to  pulmonary  tuberculosis. 

In  the  second  instance  the  mother  suffered  from  pulmonary  tuber- 
culosis, and  aborted.  Neither  the  fetus  nor  the  placenta  showed 
any  tuberculous  changes,  but  tubercle  bacilli  were  found  in  the 
intervillous  spaces  of  the  placenta. 

From  the  study  of  these  two  cases  Luenberger  draws  these  con- 
clusions: When  the  mother  suffers  from  acute  miliary  tubercu- 
losis, there  can  develop  numerous  miliary  tubercles  in  the  placenta, 
and  from  these,  tubercle  bacilli  can  penetrate  the  fetal  circulation. 
It  is  also  true  that  without  tuberculous  changes  in  the  placenta 
or  membranes  the  bacilli  can  pass  from  mother  to  child,  that  is, 
during  birth  there  can  be  sufficient  injury  to  the  chorionic  vessels 
to  allow  the  bacilli  to  pass  from  the  intervillous  spaces  into  the 
fetal  circulation. 

A.  Dietrich2  reported  a  case  which  suggests  the  possibility  of 
congenital  infection.  A  woman  with  general  tuberculosis  gave  birth 
shortly  before  her  death  to  a  premature  infant.  Tubercle  bacilli 
were  demonstrated  in  the  placenta.  The  baby  was  never  in  contact 
with  the  mother.  It  developed  well  for  the  first  two  months,  when 
an  abscess  formed  in  the  right  groin.  Following  this  there  was 
loss  in  weight  and  rales  in  the  chest.  The  child  died  in  the  third 
month.  Autopsy  showed  many  tubercles  in  the  lungs,  intestines 
and  spleen,  a  few  in  the  liver  and  a  large  lesion  in  the  portal  vein. 

Tuberculosis  of  the  placenta  has  been  described  by  many  observ- 
ers. This  is  of  importance  in  relation  to  tuberculosis  of  the  fetus 
in  proportion  as  the  fetal  or  maternal  portion  of  the  placenta  is 
involved.  It  is  certain  that  in  many  cases  only  the  maternal  portion 
is  infected,  the  fetal  remaining  uninfected. 

3.  Effect  on  the  General  Development  of  the  Fetus.— hi  a  consider- 
ation of  this  class  of  cases,  theoretically  it  may  be  viewed  from  two 
standpoints:  (1)  That  of  general  debility,  without  reference  to  a 
special  predisposition  to  tuberculous  infection;  and  (2)  that  of 
congenital  predisposition  to  tuberculous  infection.     The  question 

1  Contribution  to  Placental  and  Congenital  Tuberculosis,  Beitrage  z.  Geburtsh. 
U.  Gynak.,  1909-1910,  vol.  5. 

2  Congenital  Tuberculosis,  Berl.  klin.  Wchnschr.,  1912,  19,  877. 


340  TUBERCULOSIS  IN  PREMATURES 

of  the  possibility  of  an  inherited  immunity  against  tuberculous 
infection  is  one  which  is  open  to  great  speculation,  and  we  have 
not  been  able  to  satisfy  ourselves  that  such  an  immunity  may 
exist.  That  many  of  this  class  of  infants  seem  to  have  a  predispo- 
sition to  tuberculous  infection,  which  in  all  probability  is,  however, 
at  least  in  great  part  due  to  their  constant  exposure  and  repeated 
infection  with  the  organisms  through  contact  with  an  infected 
mother,  cannot  be  denied.  This  class  of  infants  without  really 
having  tuberculosis  often  shows  signs  of  malnutrition.  Doubtless 
many  of  them  have  a  diminished  resistance  to  all  infections  and 
more  especially  to  tuberculosis.  They  are  below  the  average  in 
development. 

4.  Systemic  Infection  of  the  Fetus.— If  tuberculous  changes  are 
present  in  the  body  at  the  time  of  birth,  if  the  infant  is  born  alive, 
the  disease  leads  to  early  death  in  the  majority  of  cases,  generally 
within  the  first  week  of  life. 

In  a  great  number  of  cases  in  which  tuberculosis  is  transmitted 
in  utero,  more  especially  in  the  last  days  of  pregnancy,  or  intra- 
partum, the  disease  remains  clinically  latent  during  the  first  days 
of  life,  and  may  not  become  manifest  for  two  or  three  months. 
The  infection  may,  however,  be  entirely  overcome.  These  cases 
may  be  described  as  the  latent  forms  of  tuberculosis.  Of  the  28 
instances  of  congenital  tuberculosis  of  which  we  have  definite  records 
at  hand,  10  infants  were  born  prematurely,  and  2  of  these  were 
still  births.  Two  of  the  living  premature  infants  survived  for  three 
months,  the  other  6  living  from  one  day  to  two  months.  Of  the 
infants  born  at  full  term  all  died  before  the  fifth  month  of  life. 

5.  Results  as  They  Affect  the  Future  Development  of  the  Infant, 
Which  May  be  Bom  at  Full  Term,  Without  Manifest  Evidence  of 
Congenital  Debility.— The  future  development  of  this  class  of 
cases  is  dependent  upon  their  freedom  from  congenital  infection, 
their  protection  against  postnatal  infection  and  their  general 
resistance. 

Symptoms.— Clinical  data  of  tuberculosis  of  the  new-born  pre- 
mature or  full  term  are  so  scant  that  no  conclusions  can  be  drawn 
as  to  the  symptomatology.  The  combination  of  enlargement  of 
the  spleen,  high,  irregular  temperature  and  enlargement  of  the 
liver,  together  with  tuberculosis  in  the  mother  is  very  suggestive. 
The  infants  are  usually  below  weight  at  birth,  pallid  and  may 
show  a  positive  tuberculin  reaction  in  the  sixth  to  seventh  week 
of  life. 

Treatment.— It  is,  of  course,  of  the  utmost  importance  that  very 
careful  hygienic  and  dietetic  measures  be  instituted  at  the  earliest 
opportunity.  There  are  no  specific  cures  or  worth-while  medicinal 
measures.  The  critical  question  is  that  of  the  advisability  of 
nursing. 


TREATMENT  341 

In  general  nursing  should  under  all  circumstances  be  forbidden 
in  open  pulmonary  tuberculosis  of  the  mother,  and  the  same  is 
advisable  also  in  every  active  tuberculosis.  The  prohibition  of 
nursing  in  these  cases  has  for  its  purpose  the  removal  of  the  infant 
from  the  coughing  mother— from  the  tuberculous  environment— 
and  is  done  more  because  of  the  danger  of  inhalation  tuberculosis 
than  because  of  the  possibility  of  an  eventual  transmission  of  the 
bacilli  by  the  mother's  milk.  Marked  tuberculosis  of  the  mother 
should  in  all  events  be  a  contraindication  against  nursing  for  the 
benefit  of  both.  In  such  a  case  it  is  the  duty  of  the  physician  to 
do  all  in  his  power  to  accomplish  the  removal  of  the  infant  from 
the  neighborhood  of  the  mother  as  soon  as  possible,  at  least  for  the 
first  months  of  life. 

In  the  cases  of  mothers  proven  to  be  tuberculous,  who  show  no 
manifest  signs  at  the  time  of  delivery  and  lactation,  caution  is 
necessary.  When  the  removal  of  the  infant  from  the  mother 
encounters  insurmountable  opposition  and  the  infant  must  remain 
at  home,  then  it  is  more  advisable  in  such  cases  not  to  endanger 
the  infant  any  more  by  introducing  artificial  feeding  but  to  put 
it  to  the  breast.  If  in  the  mother  there  are  neither  clinically  nor 
physically  demonstrable  tuberculous  changes,  and  sputum  exami- 
nation is  negative,  and  if  the  tuberculosis  is  not  only  latent,  but 
also  inactive  and  is  confined  to  mild  apex  findings,  then,  when  the 
infant  remains  with  the  mother,  nursing  should  not  only  be  recom- 
mended but  strongly  urged.  If  feeding  by  a  wet-nurse  is  possible 
it  is  for  all  events  and  purposes  the  best  method  in  doubtful  cases. 
This  should  in  justice  to  the  wet-nurse  be  carried  out  by  hand- 
feeding  of  expressed  milk.  The  wet-nurse  baby  should  not  come 
in  contact  with  the  infected  infant. 


CHAPTER  XVII. 
EDEMA  AND  SCLEREDEMA  IX  PREMATURE  INFANTS. 

Besides  asphyxia  and  hypothermia  there  is  a  tendency  to  edema 
in  small  premature  infants.  This  occurs,  sometimes  during  birth, 
but  more  frequently  during  the  first  days  of  life,  as  edema  of  the 
extremities  and  the  genitalia.  In  contradistinction  to  the  general 
view  that  these  edemas  and  scleredema  are  to  be  regarded  as 
sequela?  of  subnormal  temperature,  it  must  be  emphasized  that 
these  edematous  conditions  are  not  uncommon  in  small  prematures, 
and  that  they  may  occur  even  in  utero.  In  this  connection  atten- 
tion may  be  called  to  congenital  general  dropsy  and  to  other  localized 
edemas,  that  have  been  observed  by  others  in  premature  infants 
immediately  after  birth,  or  in  the  new  born.  (Ballantyne,  Link, 
Kirk,  Oswald,  Chiari.) 

Special  forms  of  edema  are  scleredema  and  sclerema.  It  is  not 
always  possible  to  make  sharp  differentiations  between  these  and 
other  forms  of  edema.  Scleredema  is  designated  that  form  of 
edema  in  which  the  skin  is  hard  and  taut,  while  sclerema  is  that 
condition  in  which  the  skin  is  hard  and  dried  out.  Many  authors 
emphasize  that  in  an  individual  case  the  sclerema  is  not  to  be 
distinguished  from  scleredema,  since  they  are  only  quantitative 
differences  of  the  same  process.  Ylppo1  believes  that  it  depends 
entirely  upon  the  water  richness  of  the  tissues,  whether  the  skin 
feels  pasty  hard  (scleredema)  or  wooden  hard  (sclerema). 

Etiology.— As  far  as  etiology  is  concerned  we  cannot  make  special 
differences.  According  to  experience,  the  skin  upon  the  external 
portion  of  the  thigh,  whenever  edema  of  the  feet  is  present,  feels 
always  somewhat  tougher  and  harder  (scleredemic),  in  comparison 
to  soft  edema  of  the  genital  region  or  of  the  inner  surface  of  the 
thigh  and  leg.  Because  these  differences  in  consistency  are  demon- 
strable in  many  premature  infants  a  few  hours  after  birth,  we 
have  to  consider  special  anatomical  conditions  as  factors  responsible 
for  their  production.  The  younger  the  infant,  the  thinner  is  the 
fatty  cushion.  On  the  external  surface  of  the  thigh  it  is  several 
millimeters  thick  even  in  the  smallest  prematures,  while  in  other 
regions  the  subcutaneous  fatty  tissue  is  not  well  developed.  The 
occurrence  of  hard  edema  on  the  external  surface  of  the  thigh  with 

1  Ztschr.  f.  Kinderh.,  1913,  24,  53. 


SYMPTOMS  343 

simultaneous  occurrence  of  soft  edema  in  other  portions,  forces 
upon  us  the  conclusion  that  besides  the  water  richness  it  also 
depends  upon  the  richness  of  the  subcutaneous  fatty  tissue,  whether 
or  not  an  edematous  portion  of  the  skin  feels  somewhat  harder. 

Now,  new-born  infants,  and  also  prematures,  whose  bodies  are 
especially  rich  in  water,  lose  in  weight  during  the  first  days  of  life, 
and  thus  it  is  easy  to  understand  that  the  water  content  of  the  skin 
and  of  the  subcutaneous  fatty  tissues  gradually  becomes  less. 
According  to  Langer1  and  Knoepfelmacher,2  the  subcutaneous  fat 
contains  chiefly  palmitic  and  stearic  acids,  and  proportionately 
only  a  small  quantity  of  oleic  acid.  The  fat  of  the  new-born  infant 
is  therefore  even  with  ordinary  body  temperature  somewhat  harder 
than  the  fat  of  the  adult,  which  is  rich  in  oleic  acid.  The  usual  very 
high  water  content  of  the  fatty  tissue  in  the  new-born  infant  makes 
it  of  normal  softness  during  ordinary  temperature.  It  is  easy  to 
understand  that  the  oleic-acid-poor,  fatty  tissue  begins  to  feel 
hard  when  the  water  disappears  from  the  interstitial  spaces  of  the 
fatty  tissue. 

Symptoms.  — In  small  prematures  that  are  observed  carefully 
after  birth,  we  may  notice  that  the  legs,  and  especially  the  feet 
and  hands,  may  begin  to  swell  in  from  five  to  seven  hours  after 
birth.  These  swellings  often  occur  no  matter  whether  the  infant 
is  transferred  immediately  after  birth  into  a  warming  tub,  or 
whether  it  shows  subnormal  temperature.  In  infants  with  sub- 
normal temperature  edema  occurs  more  frequently  and  is  more 
marked.  If  the  child  is  put  into  a  somewhat  inclined  position,  so 
that  the  hands  and  legs  hang  down,  then  very  soon  cyanotic  swelling 
may  be  observed  in  the  dependent  extremities.  If  we  change  the 
position  and  allow  the  head  to  be  lower  than  the  legs  then  the 
edema  disappears  in  a  few  hours. 

This  simple  experiment  shows  that  the  cause  of  the  edema 
occurring  in  the  premature  infant  during  the  first  days  or  hours 
of  life,  may  be  looked  for  in  circulatory  weakness.  Besides  this, 
the  high  water  content  of  the  tissues  and  the  ready  permeability 
of  the  blood  and  lymph  vessels  in  prematures  is  of  great  importance 
in  this  respect.  In  these  infants  edema  occurs  not  only  in  the  skin, 
or  more  properly  in  the  subcutaneous  tissues,  but  also  in  many 
other  tissues.  The  marked  tendency  to  hydrops  of  the  cavities 
and  the  high-grade  edematous  swellings  of  the  pelvic  walls  and 
brain  coverings  is  also  a  manifestation  of  this  general  property  of 
the  body  of  the  premature  infant.  It  cannot  be  denied,  of  course, 
that  hypothermia  and  initial  cooling  of  the  premature  infant  are 
of  importance  in  the  development  of  edema.     If  the  cold  easily 

1  Mathem.-naturw.  Klasse,  1881,  84,  94  (dritte  Abtlg.). 

2  Jahrb.  f.  Kinderh.,  1897,  45,  177. 


344      EDEMA  AND  SCLEREDEMA  IN  PREMATURE  INFANTS 

damages  the  small  capillaries  of  an  adult  it  does  it  even  more 
easily  in  the  premature  infant,  in  whom  the  skin  is  rich  in  water. 
The  water  evaporation,  by  producing  heat  loss,  favors  the  develop- 
ment of  lesions  of  the  capillaries.  It  is  a  mistake,  however,  to 
designate  edema  in  premature  infants  simply  as  a  sequel  of  hypo- 
thermia. 

Treatment.— In  the  treatment  of  sclerema  it  is  important  to  see 
first  that  the  water  intake  is  increased.  It  is  understood  that 
proper  care  must  be  taken  of  the  temperature  and  other  conditions. 
In  general,  the  prognosis  in  sclerema  of  the  premature  infant  is  not 
as  bad  as  has  generally  been  supposed.  If  we  succeed  in  preventing 
early  the  marked  desiccation  of  the  infant,  then  it  is  still  possible 
to  save  the  infant. 


Fig.  176. — Case  of  erythroblastosis. 


ERYTHROBLASTOSIS  FETALIS. 


Among  the  various  forms  of  congenital  dropsy,  in  which  the 
infants  are  often  prematurely  born,  erythroblastosis,  first  described 
by  Schridde1  and  named  by  Rautmann,2  is  the  least  understood. 
Congenital  generalized  edema  may  be  the  result  of  cardiac  anoma- 
lies and  diseases,  portal  obstruction,  syphilis  of  the  liver,  fetal 
peritonitis,  abnormality  of  the  D.  venosus  Arantii,  deformities  of 
the  intestines  and  diseases  of  the  kidneys.  Schridde,  in  1910, 
pointed  out  a  form  of  congenital  general  dropsy  with  hydramnios 
associated  with  a  pathological  blood  state. 

The  disorder  is  characterized  by  anasarca  and  fluid  in  the  cavities, 

1  Die  angeborene  allgeraeine  Wassersucht,  Munchen.  med.  Wchnschr.,  1910. 

2  Ueber  Blutbildung  bei  fotaler  allgemeiner  Wassersucht,  Ziegler's  Beitrage, 
1912,  54. 


ERYTHROBLASTOSIS  FETALIS  345 

tiydramnios  and  enlargement  of  the  liver  and  spleen.  The  latter 
two  organs  show  the  most  marked  changes,  which  consist  of  the 
accumulation,  both  inside  and  outside  of  the  bloodvessels,  of  large 
numbers  of  erythroblasts  and  a  smaller  number  of  other  marrow- 
cells.  The  lymph  follicles  in  the  spleen  are  absent  and  the  liver 
cells  are  crowded  out.  Accumulations  of  erythroblasts  in  small 
numbers  may  be  found  in  the  kidneys,  adrenals  and  lymph  glands. 
Erythroblasts  appear  in  the  blood  in  greatly  increased  numbers 
and  they  show  very  often  mitotic  processes.  The  heart  is  often 
hypertrophied. 

Because  of  the  presence  of  hemosiderin  in  the  spleen  and  liver, 
Schridde  was  led  to  believe  that  the  disease  was  due  to  a  severe 
anemia  with  compensatory  hematopoiesis  having  no  relation  to 
syphilis.  Others  have  assumed  that  the  extramedullary  formation 
of  blood  corpuscles  was  due  to  some  form  of  unknown  toxic  action. 
Chiari3  described  an  infant  in  whom  there  was  no  blood  pigment  in 
the  liver  or  spleen,  and  consequently  no  indications  of  any  ante- 
cedent destruction  of  blood  cells.  Fischer,4  in  his  examination  of 
the  older  literature,  came  to  the  conclusion  that  many  of  the  cases 
described  as  congenital  leukemia  were  probably  instances  of  erythro- 
blastosis. 

3  Ein  Beitrag  zur  Kenntnis  der  sogenannten  fotalen  Erythroblastose,  Jahrb.  f. 
Kinderh.,   1914,  80,  561. 

4  Die  allgemeine  angeborene  Wassersucht,  Deutsch.  rned.  Wchnschr.,  1912,  Xo.  9. 


CHAPTER  XVIII. 
DISEASES  PECULIAR  TO  PREMATURE  INFANTS. 

RACHITIS  IN  PREMATURE  INFANTS. 

The  early  appearance  of  rachitic  manifestations  in  premature 
infants  has  been  noted  by  many  observers,  especially  associated 
with  spasmophilia  and  anemia.  Most  prematurely  born  infants 
become  rachitic— the  lower  the  weight,  the  more  certainly— and 
even  human  milk  is  not  an  absolute  protection  against  this. 

Huenekens1  was  able  to  collect  70  cases  of  prematures  and  twins, 
of  which  58  developed  definite  signs  of  rachitis  (82  per  cent).  The 
time  of  occurrence  was  interesting,  inasmuch  as  of  33  cases  seen 
for  the  first  time  at  or  before  four  months,  27,  or  81  per  cent,  showed 
evidence  of  rachitis  at  that  time.  The  first  symptom  usually  noted 
was  craniotabes,  which  in  3  instances  was  already  present  at  six 
weeks.  Langstein2  observed  it  frequently  in  the  third  to  the  fourth 
month  of  life  and  not  much  less  often  was  the  tendency  to  con- 
vulsions (hyperirritability  of  the  nervous  system  of  these  infants) . 

Ylppo3  observed  commonly  a  megacephalus  in  connection  with 
rachitis  of  the  skull,  which  often  left  marks  permanent  for 
all  life.  These  have  to  be  regarded  as  characteristics  of  the 
prematures  and  not,  as  unfortunately  is  often  the  case,  as  signs  of 
special  "constitutional  degeneration."  Along  with  this  mega- 
cephalus with  its  somewhat  large,  plump  skull,  there  is  asymmetry, 
which  is  not  congenital  but  is  produced  in  a  mechanical  way  by  the 
pressure  of  the  infant's  head  in  the  first  months  of  life  and  the 
softness  of  the  skull. 

The  narrow  thorax  with  its  more  or  less  marked  signs  of  rachitis 
may  also  be  regarded  as  a  peculiarity  characteristic  of  the  smallest 
prematures  but  not  of  those  of  greater  weight.  This  is  not  to  be 
confused  with  the  early  functional,  funnel  chest  which  can  be 
demonstrated  in  the  first  weeks  of  life  and  is  due  to  the  softness  of 
the  ribs  in  the  smaller  prematures.  This  leads  to  further  deformity 
of  the  thorax,  as  the  marked  contraction  of  the  lower  half,  which 
is  the  result  of  the  congenital  softness  of  the  ribs  and  the  rachitic 
affections  later  developing.  The  constriction  around  the  chest 
is  best  seen  about  the  insertion  of  the  diaphragm. 

1  Jour.  Lancet,  1917,  37,  804. 

2  Ztschr.  f.  Kinderh.,  1916,  15,  49.  3  Ibid.,  1919,  20,  212. 


kACHITIS  IN  PRE MATURE  INFANTS 


347 


The  rachitic  rosary  is  very  prominent  in  prematures  and  is 
explained  on  the  basis  of  the  constant  respiratory  movements 
leading  to  deformities  and  marked  enlargement  of  the  epiphyses 
of  the  ribs. 

The  long  cylindrical  bones,  however,  only  exceptionally  show 
enlargements  of  the  epiphyses  in  prematures,  although  rachitic 


Fig.  177.  —  Rickets — first  stage. 


changes  appear  in  these  bones  very  early.  The  process  in  these 
bones  results  rather  in  bone  absorption  and  fringing  of  the  epiph- 
yses than  in  marked  proliferation,  which  is  the  rule  in  strong 
full-term  rachitic  infants.  The  explanation  of  this  feature  in 
prematures  may  be  in  the  fact  that  the  rachitis  appearing  very 
early  is  already  at  end  by  the  time  the  infant  learns  to  walk,  whereas 


348 


DISEASES  PECULIAR  TO  PREMATURE  INFANTS 


in  the  full-term  infant  the  hyperplastic  epiphyseal  enlargement 
occurs  as  a  compensatory  process  in  the  period  when  the  lower 
extremities  are  called  upon  to  support  the  weight  of  the  body. 
In  the  absence  of  special  rachitic  curvatures  and  epiphyseal  enlarge- 
ments of  the  long  bones,  we  cannot  therefore  exclude  rachitis  in 


Fig.  178. — Rickets — second  stage. 


the  premature.     Histological  examination  shows  a  characteristic 
picture  in  the  absence  of  marked  external  manifestations. 

Etiology.— The  etiology  of  rachitis  in  premature  and  full-term 
infants  has  been  the  subject  of  much  discussion.  Huenekens 
believes  that  the  explanation  may  be  found  in  that  the  chemical 
constitution   of  prematures  is  abnormal.     Their  salt  content  is 


RACHITIS  IN  PREMATURE  INFANTS  349 

far  below  normal.  Birk1  found  that  a  four-months  fetus  contained 
14  gm.  of  ash,  at  six  months  30  gin.  at  nine  months  100  gm.,  show- 
ing that  two-thirds  of  the  minerals  were  taken  on  during  the  lasl 
three  months  of  fetal  life.  In  the  new  born  fully  75  per  cent  of  this 
ash  is  made  up  of  calcium  and  phosphate,  the  chief  constituents 
of  the  bones.  Huenekens  believes,  therefore,  that  the  more  pre- 
mature the  infant,  the  greater  will  be  the  deficiency  of  calcium 
and  other  minerals,  so  that  by  the  third  or  fourth  month  of  extra- 
uterine life  the  supply  is  entirely  exhausted  and  rachitis  results. 

Underfeeding  is  another  factor  in  the  development  of  rickets 
in  the  premature.  The  low  calcium  content  of  human  milk  and 
the  difficulty  of  metabolizing  even  this  food  in  sufficient  quanti- 
ties to  prevent  drawing  on  the  inherited  supply  may  be  an  active 
factor.  The  artificially  fed  are  especially  prone  to  develop  severe 
rickets.  If  the  diet  contains  sufficient  milk  the  tendency  to  develop 
the  disease  is  less  than  when  fed  mainly  on  cereals  and  proprietary 
cereal  foods  with  only  small  amounts  of  milk.  A  diminished 
calcium  retention  (negative  calcium  balance)  exists  in  the  florid 
stage  of  rickets,  even  though  the  intake  is  ample.  A  deficiency  of 
calcium  in  the  diet  while  important  in  itself  is  probably  not  the 
precipitating  factor.  It  has  been  shown  experimentally  in  puppies 
that  a  diet  containing  an  abundance  of  calcium  does  not  prevent 
rickets  when  the  diet  is  deficient  in  other  factors. 

The  average  normal  inorganic  phosphorus  concentration  in  the 
serum  is  about  5  mg.  per  100  cc.  Howland  and  Kramer2  found 
that  in  all  patients  in  the  active  stage  of  rickets  the  concentration 
of  inorganic  phosphorus  in  the  blood  serum  was  low  and  that  in  all 
children  under  two  and  a  half  years  of  age,  in  whom  an  inorganic 
phosphorus  content  of  the  serum  of  3  mg.  or  less  was  found,  active 
rickets  was  present.  With  the  healing  of  the  process  in  the  bones 
that  occurred  after  cod-liver  oil  medication,  the  phosphorus  rose 
gradually  to  normal.  These  facts  led  them  to  consider  the  presence 
of  a  low  percentage  of  inorganic  phosphorus  in  the  serum  of  a  young 
child  as  nearly  conclusive  evidence  of  active  rickets.  They  Relieve 
that  there  is  constantly  a  marked  and  for  the  causation  of  the 
pathological  lesions,  an  important  deficiency  in  inorganic  phos- 
phorus. To  this  deficiency  they  ascribe  the  failure  of  calcium 
deposition. 

The  phosphorus  content  of  the  blood  can  be  increased  by  feed- 
ing phosphorus  per  mouth.  Marriott,3  working  with  artificial  blood, 
found  that  by  small  increases  in  the  phosphorus  content,  a 
precipitate  resembling  in  composition  the  salts  of  bone  was  formed. 

1  In'Monatsschr.  f.  Kinderh.,  1910,  1,  644. 

2  Jour.  Biol.  Chem.,  1920.  43,  35. 

?  Report  of  Thirty-second  Meeting  of  Am.  Fed.  Sqc.     Arch.  Ped.,  1920,  vol.  37, 


350  DISEASES  PECULIAR  TO  PREMATURE  INFANTS 

Phemister1  applied  these  experiments  to  children  and  noticed  by 
roentgenogram  studies  that  phosphorus  affected  the  normal  bones 
of  children  as  it  did  Wegner's2  animals  and  that  the  accumulation 
of  calcium  and  overproduction  of  bone  in  the  metaphysis  continued 
for  some  time  even  after  the  administration  of  phosphorus  was 
discontinued.  He  has  more  recently  reported  similar  results  in 
rachitic  infants. 

McCollum  and  his  associates,3  4  in  a  study  of  the  effect  on  the 
growth  and  development  in  rats,  came  to  the  conclusion  that  the 
etiological  factor  is  to  be  found  in  an  improper  dietetic  regimen. 
Their  experiments  showed  that  the  majority  of  young  rats  devel- 
oped pathological  conditions  of  the  skeleton  having  a  fundamental 
resemblance  to  rickets  when  fed  upon  diets  low  in  both  fat  soluble 
vitamines  and  phosphorus.  When  they  modified  this  diet  so  that 
the  deficiency  in  phosphorus  is  compensated  for  by  the  addition  of 
a  complete  salt  mixture,  containing  the  phosphate  ion,  the  deficiency 
in  fat  soluble  factors  still  existing,  no  pathological  changes  of  a 
rachitic  nature  developed.  They,  therefore,  concluded  that  a 
deficiency  in  this  vitamine  cannot  be  the  sole  cause  of  rickets.  In 
summarizing,  they  state  that  the  phosphate  ion  in  the  diet  may  be 
a  determining  influence  for  or  against  the  development  of  rickets, 
but  that  these  findings  should  not  exclude  the  absence  of  fat  soluble 
vitamine  from  consideration  as  an  etiological  factor  in  the  produc- 
tion of  rickets  and  kindred  diseases,  since  the  level  of  the  blood 
phosphate  is,  in  all  probability,  determined  in  part  by  the  amount 
of  fat  soluble  vitamine  available  for  the  needs  of  the  organism. 

Summarizing,  it  appears  that  rickets  is  a  nutritional  disturbance 
especially  affecting  the  osseous  and  muscular  system,  with  resulting 
lesions  which  prevent  the  bones  and  muscles  from  utilizing  calcium, 
thus  leading  to  a  diminished  retention  of  this  element,  although 
there  is  plenty  of  it  in  the  food  intake  and  in  the  blood.  Phos- 
phorus probably  plays  an  intermediate  role  in  influencing  the  forma- 
tion and  deposition  of  the  lime  salts  in  bone.  Whether  the  diet 
plays  its  role  by  directly  interfering  with  the  calcium  and  phos- 
phorus metabolism  due  to  lack  of  an  antirachitic  factor  or  indirectly 
by  causing  an  underlying  nutritional  disturbance  is  open  to  con- 
jecture. 

Hygiene  is  an  important  factor  in  that  improper  hygiene  results 
in  impaired  metabolism  with  a  resulting  inability  to  properly 
utilize   the   dietetic   constituents   even   when   properly   balanced. 

1  Effects  of  Phosphorus  on  Growing  Normal  and  Diseased  Bones,  Jour.  Am.  Med. 
Assn.,  1918,  70,  1737. 

-   Yirchow's  Arch.  f.  Path.  Anat.,  1872,  55,  9. 

3  McCollum,  Simmonds,  Parsons  and  Shipley:     Jour.  Biol.  Chem.,  1921,  45,  333. 

4  Shipley  and  Park,  McCollum  and  Simmonds:  Johns  Hopkins  Hosp.  Bull., 
1921,  32,  160. 


ANEMIA  OF  PREMATURE  INFANTS  351 

Infections  play  a  similar  role.  Impairment  of  the  body  functions 
also  directly  affects  the  glands  of  internal  secretion  with  secondary 
disturbances  folloAving  such  dysfunction.  Therefore,  "while  an 
impairment  of  mineral  metabolism  precipitates  the  clinical 
symptoms,  one  or  several  of  the  secondary  factors  may  have  an 
important  relation  to  the  utilization  of  phosphorus  and  calcium. 

Treatment.— Our  therapy  is  along  the  same  lines  as  in  full-term 
children  with  special  stress  on  the  feeding  of  human  milk.  Fresh 
air  and  sunshine  in  the  older  children  and  the  observation  of  careful 
hygiene  for  all  are  without  doubt  highly  important. 

Diet  must  receive  very  careful  consideration.  In  the  very 
young  the  ideal  food  is,  of  course,  mother's  milk.  Where  artificial 
feeding  must  be  instituted  the  amount  of  cow's  milk  should  be 
minimal,  and  cereals  and  vegetables  started  early.  Orange  juice 
diluted  with  water  should  be  given  in  small  amounts  from  the 
second  or  third  months  (one  to  four  teaspoonfuls  daily).  After, 
the  first  month  the  diluent  in  the  milk  mixtures  should  be  a  cereal 
water  (one  tablespoonful  of  whole  barley  or  oatmeal  to  the  quart 
of  water— and  not  the  dextrinized  cereal  flours).  From  the  third 
month  cereal  should  be  fed.  After  the  fifth  month  vegetable 
soups  should  be  given,  substituting  an  ounce  of  soup  for  an  equal 
amount  of  bottle-feeding.  By  the  sixth  or  seventh  month  a  milk- 
feeding  should  be  replaced  by  a  vegetable-soup  meal. 

Cod-liver  oil  with  phosphorus  in  a  preparation  containing  0.0003 
gm.  (airo  gr-)  to  each  4  cc  (1  dr.)  oleum  morrhuse,  is  a  most  practical 
mixture  and  can  be  administered  to  most  infants  by  the  fourth  to 
the  sixth  week,  beginning  with  |  cc  doses  twice  daily  and  increasing 
to  4  cc  twice  daily  by  the  fifth  month.  The  work  of  Schloss1  has 
shown  that  the  addition  of  a  calcium  salt  to  cod-liver  oil  with  phos- 
phorus further  enhances  the  value  of  the  mixture.  Such  a  prepara- 
tion is  the  tricalcium  phosphate  C.  P.  (10  per  cent)  in  emulsion  of 
cod-liver  oil  U.  S.  P. 

ANEMIA  OF  PREMATURE  INFANTS. 

Closely  associated  with  rachitis  in  premature  infants  is  an  anemia, 
which  develops  quite  regularly  and  strikingly  during  the  first  three 
months  of  life.  In  our  previous  discussion  of  the  physiology  of 
the  blood  we  noted  from  the  work  of  Kunckel,  Lichtenstein,  Lande 
and  others  (p.  67,  et  seq.)  that  in  contrast  with  full-term  infants,  in 
the  premature  there  is  a  greater  number  of  nucleated  red  blood 
corpuscles,  a  more  frequent  appearance  of  myeloblasts  and  myelo- 
cytes during  the  first  days  of  life,  a  lesser  development  of  absolute 

1  Zur  Therapie  der  Rachitis,  Jahrb.  f.  Kiaderh.,  1914,  79,  194. 


352  DISEASES  PECULIAR  TO  PREMATURE  INFANTS 

and  relative  leucocytosis,  and  a  greater  number  of  immature  leuco- 
cyte forms.  There  is  also  a  distinct  and  very  early  hemoglobin 
impoverishment  of  the  blood,  which  reaches  its  maximum  in 
about  the  third  to  the  fourth  month. 

Etiology.  —  Kunckel1  believed  that  this  anemia  appearing  regu- 
larly in  the  first  three  months  of  life  was  physiological  and  was  of 
the  chlorotic  type.  His  children  improved  in  the  second  half 
year  of  life,  but  if  infection  was  present  any  time  the  infants  devel- 
oped a  severe  secondary  anemia  much  more  readily  than  full-term 
infants.  His  opinion  was  that  the  anemia  did  not  rest  on  an 
alimentary  basis  but  was  due  to  an  insufficiency  in  hemoglobin 
metabolism,  beside  a  deficient  iron  storage. 

Pfaundler2  felt  that  the  anemia  was  closely  related  to  a  lack  of 
fresh  air  and  sunshine. 

Lichtenstein3  fixes  the  early  anemia  in  the  first  three  months  of 
life  as  a  hypoplastic  condition  resulting  through  insufficiency  of  the 
hematopoietic  system.  The  later  oligochromemia,  after  spon- 
taneous retrogression  of  the  oligocythemia,  he  considers  as  a  sequel 
of  the  impoverished  iron  storage.  He  opposes  the  hypothesis  of 
alimentary  anemia  of  Czerny  and  Kleinschmidt.  The  theory  of 
the  harmful  action  of  milk  on  the  hematopoietic  apparatus  he 
asserts  is  disproved  by  the  excellent  results  attending  the  feeding 
of  human  milk  and  the  administration  of  small  amounts  of  ferrous 
lactate. 

Lande4  is  in  accord  with  the  opinions  of  Kunckel  and  Lichtenstein. 
As  evidence  in  favor  of  the  importance  of  iron  storage  he  em- 
phasizes the  fact  that  eighth-month  infants  in  the  course  of  the 
second  quarter  year  of  life  show  a  higher  percentage  of  hemoglobin 
and  erythrocytes  than  do  seventh-month  prematures. 

The  examination  by  Lande  of  the  bone  marrow  in  ten  prematures 
disclosed  no  decisive  picture  except  an  insufficiency  of  the  granulo- 
cyte system.  Thus  he  disproves  the  theory  that  the  basis  of  the 
anemia  rests  with  a  defective  erythropoietic  system. 

Lichtenstein  feels  that  there  is  no  marked  difference  in  the  blood 
picture  of  artificially  and  breast-fed  prematures.  Examination  of 
twenty-eight  cases  artificially  fed,  many  of  whom  were  born  of 
nephritic,  anemic  and  tuberculous  mothers,  showed  no  great  differ- 
ences in  the  blood  picture  from  those  breast-fed. 

Symptoms.— The  most  marked  symptom  observed  by  Lande  was 
pallor  of  the  skin,  which  he  saw  with  great  regularity.  It  appeared 
especially  early  as  a  fore-runner  of  icterus,  which  in  prematures  is 

i  Ztschr.  f.  Kinderh.,  1915,  13,  101. 

2  Verhand.  d.  Ges.  f.  Kinderh.,  Breslau,  1904,  21,  24. 

3  Svenska,  LaKaresa  As  Kapets  Handlingor,  1917,  No.  4,  43. 
*  Ztschr.  f,  Kinderh.,  1918,  22,  299. 


ANEMIA  OF  PREMATURE  INFANTS  353 

constantly  present.  The  question  arises  as  to  whether  the  anemia 
is  promoted  by  the  icterus  or  both  icterus  and  anemia  are  not 
bound  up  with  a  third  factor— the  maturity  of  the  infant. 

One  can  differentiate  various  grades  of  pallor,  which  is  earliest 
and  most  clearly  seen  in  the  face  and  well  agrees  in  general  with 
the  degree  of  pathological  blood  change.  The  most  marked  form 
of  anemia  gives  the  infant  a  bluish,  transparent  appearance,  or  a 
waxen,  yellowish  color,  somewhat  akin  to  the  infants  with  severe 
congenital  syphilis  or  chronic  pyelitis.  The  picture  is  accentuated 
by  the  outstanding  bluish  veins,  especially  prominent  on  the  skull 
and  abdomen.  The  ears  are  transparent  with  hardly  the  vestige 
of  a  rosy  hue  and  the  mucous  membranes  are  very  pale. 

The  pallor  after  open-air  treatment  has  been  noted  to  give  way 
to  a  rosy  hue,  but  only  in  a  few  cases  is  there  a  parallel  permanent 
increase  in  hemoglobin.  However,  with  the  increase  in  hemoglobin 
and  erythrocytes  in  the  fourth  to  sixth  months,  the  color  simul- 
taneously improves. 

In  Lande's  series  the  appetite  of  the  infants  was  in  general  satis- 
factory. There  was  no  stupor,  especially  in  the  more  anemic. 
There  were  no  elevations  of  temperature,  as  described  by  some 
observers,  present  with  the  marked  blood  changes. 

Marked  glandular  and  splenic  swelling  was  not  observed  by 
Kunckel  or  Lande,  but  Lichtenstein  states  that  splenic  tumor  was 
present  in  two- thirds  of  his  children. 

Lichtenstein  finds  that  the  blood  pictures  in  the  well  breast-fed 
prematures  and  those  showing  alimentary  disturbances  are  both 
of  the  chlorotic  type  and  differ  mainly  in  degree.  He  also  believes 
that  the  clinical  picture  described  as  pseudoleukemic  anemia  is  a 
severe  form  of  secondary  anemia  and  is  not  a  distinct  clinical 
entity. 

Treatment.— For  the  general  and  hygienic  treatment  of  primary 
and  secondary  anemia,  the  suggestions  made  for  general  measures 
in  the  care  of  rachitis  should  be  followed.  The  infants  must  above 
all  be  given  the  advantage  of  a  good  environment,  plenty  of  fresh 
air  and  sunshine. 

Iron  therapy  for  the  purpose  of  increasing  the  iron  content  of  the 
tissues  and  the  hemoglobin  has  met  with  individual  success.  It 
should  be  started  early.  Among  the  iron  compounds  to  be  recom- 
mended are  ferri  carbonas  saccharatus  0.25  to  0.5  gm.,  ferri  et 
ammonii  citratis  0.06  to  0.12  gm.  or  ferri  Iactis  0.12  to  0.25  gm. 
one  to  three  times  daily. 

Small  doses  of  liquor  potassii  arsenitis  0.03  to  0.0(5  cc  may  be 
given  one  or  two  times  daily  for  short  periods.  The  infant  should 
be  observed  carefully  for  evidence  of  arsenic  intoxication. 

In  the  presence  of  congenital  syphilis,  mercurial  therapy  is  impera- 
23 


354 


DISEASES  PECULIAR  TO  PREMATURE  INFANTS 


tive  and  may  be  combined  with  the  arsenic  treatment  to  good 
advantage. 

Lande  suggests  the  use  of  intramuscular  injections  of  normal 
human  blood.  The  blood  is  drawn  from  the  vein  of  a  healthy  adult 
with  a  Wassermann  needle  and  allowed  to  flow  into  a  flask  containing 
small  glass  beads.  It  is  shaken  about  five  minutes  and  thus  defibrin- 
ated  and  before  injection  is  passed  through  a  double  thickness  of 
sterile  gauze.  In  individual  cases  the  result  may  be  very  good, 
however,  in  a  series  of  thirteen  cases  he  was  unable  to  demonstrate 
a  marked  increase  in  hemoglobin  or  red  corpuscles. 

It  is  of  the  greatest  importance  to  bear  in  mind  that,  as  in  the 
case  of  rachitis,  the  treatment  for  anemia  should  be  started  early. 
It  is  our  custom  to  begin  the  prophylactic  treatment  of  both  of 
these  conditions  in  the  first  weeks  of  life. 

SPASMOPHILIC  DIATHESIS  IN  PREMATURE  INFANTS. 

TETANY. 

Besides  anemia  and  rachitis,  spasmophilia  is  one  of  the  most 
interesting  clinical  peculiarities  of  premature  infants.     The  term 


Fig.  179. — Spasmophilia.     Infant  in  state  of  "tetany. 


spasmophilia  is  used  here  in  the  sense  of  designating  the  mani- 
festations occurring  in  the  nursling,  while  tetany  refers  to  the  older 
child.    Typical  tetany  with  all  its  characteristic  symptoms,  the 


SPASMOPHILIC  DIATHESIS  IN  PREMATURE  INFANTS     355 

phenomena  of  Erb,  Chvostek  and  Trousseau,  carpopedal  spasms, 
tonic  and  clonic  convulsions  and  laryngospasm,  has  rarely  been 
observed  in  the  premature  new  born.  While  spasmophilia  is  by 
no  means  rare  in  artificially  fed,  full-term  infants,  it  is  found  quite 
frequently  in  prematures,  and  not  only  in  those  artificially  fed,  but 
also  in  the  infants  fed  on  human  milk.  With  breast-feeding, 
however,  spasmophilic  manifestations  occur  only  exceptionally  and 
lead  to  convulsions  usually  only  in  connection  with  infections. 

Etiology  and  Symptoms.— There  are  other  predisposing  factors 
besides  feeding  in  the  development  of  spasmophilia  in  prematures. 
We  may  not  call  these  factors  constitutional,  since  in  all  proba- 
bility they  depend  on  the  various  noxse  of  the  extra-uterine  life. 
These  lead  to  a  hyperirritability  of  the  nervous  system.  The 
nervous  system  in  all  premature  infants  is  extraordinarily  lowered 
during  the  first  weeks  of  life  against  all  possible  stimuli,  including 
the  electrical. 

On  the  other  hand,  however,  it  is  a  fact  that  feeding  plays  a  very 
important  role  in  the  development  of  spasmophilia  and  above  all 
in  the  appearance  of  convulsions.  Not  uncommonly  one  observes 
prematures  in  whom  the  spasmophilic  manifestations  remain  latent 
as  long  as  breast-feeding  is  continued,  but  appear  shortly  after 
the  institution  of  artificial  feeding.  Langstein1  reported  a  case  of 
twins  in  whom  convulsions  always  appeared  shortly  after  artificial 
feeding  was  added  to  human  milk.  There  were  individual  differ- 
ences between  the  twins  in  the  ease  with  which  the  convulsions 
could  be  produced.  In  one  infant  they  developed  within  seven  to 
twelve  days  after  the  addition  of  artificial  food,  in  the  other 
within  eighteen  to  twenty  days. 

If  we  systematically  examine  the  electrical  irritability  in  a  large 
number  of  prematures  we  can  determine  that  in  infants  fed  on 
human  milk  the  electrical  irritability  may  increase  to  such  an 
extent  as  to  be  C.O.C.  less  than  5  milliamperes  at  the  age  of  six 
to  ten  weeks.  Rosenstern2  studied  the  spasmophilic  diathesis  in 
premature  infants  and  noted  individual  differences  in  the  electrical 
hyperirritability,  which  appeared  very  early  and  frequently  in 
breast-fed  prematures.  He  was  able  to  demonstrate  spasmophilia 
in  the  form  of  electrical  hyperirritability  in  76  per  cent  of  the 
prematures  and  debilitated  infants  that  he  examined. 

In  Ylppo's  series  the  electrical  hyperirritability  was  not  as 
frequent.  Among  the  42  premature  infants  in  whom  he  was  able 
to  determine  the  electrical  reaction  systematically  during  the  first 
three  to  six  months  of  life,  only  15  infants  (35  per  cent)  showed 
C.O.C.   less  than  5  milliamperes.     In  3  cases  electrical  hyper- 

1  Kassowitz,  Festschrift,  Berlin,  1912. 

2  Ztschr.  f.  Kinderh.,  1913,  8,  171. 


356  DISEASES  PECULIAR  TO  PREMATURE  INFANTS 

irritability  was  already  present  in  the  second  month.  One  infant 
was  on  human  milk-feeding  and  the  other  on  mixed  feeding.  In 
the  third  month  electrical  hyperirritability  appeared  in  3  additional 
infants.  It  was  most  frequently  present  in  the  fourth  month. 
From  this  data  it  seems  that  spasmophilia  appears  earlier  in  pre- 
mature than  in  full-term  infants. 

Ylppo1  also  noted  the  especially  interesting  fact  that  the  great 
tendency  to  electrical  hyperirritability  and  convulsions,  which  he 
determined  in  many  artificially  fed  premature  infants,  three  to 
four  months  old,  gradually  disappeared  in  the  fifth  to  sixth  months 
without  any  treatment,  while  the  feeding  remained  the  same. 
In  other  children  it  often  took  months  before  the  electrical  hyper- 
irritability disappeared. 

In  premature  infants  we  frequently  find  very  interesting  devi- 
ations from  the  generally  recognized  symptoms  of  spasmophilia. 
It  is  not  at  all  infrequent  that  the  cardinal  symptom  of  spasmo- 
philia (Erb's  symptom),  the  electrical  hyperirritability  of  the 
peripheral  nerves,  may  be  absent,  in  spite  of  the  manifest  signs 
of  the  disorder.  To  know  this  is  very  important,  because  we  know 
that  there  exist  conditions  in  premature  infants  in  which  the 
electrical  reaction  remains  increased  for  months,  although  no  con- 
vulsions occur.  This  lack  of  electrical  hyperirritability  in  spasmo- 
philic convulsions  in  prematures  exists  not  only  after  convulsions 
have  taken  place— which  could  easily  be  accounted  for  by  exhaus- 
tion of  the  nervous  system— but  also  before  the  appearance  of 
convulsions. 

In  individual  cases  there  may  be  pathologically  increased  elec- 
trical hyperirritability,  even  when  the  electrical  reaction  does  not 
go  below  5  milliamperes  for  C.O.C.  Rosenstern  called  attention 
to  this  fact  and  pointed  out  that  the  value  below  5  milliamperes 
for  C.O.C,  which  is  regarded  as  pathognomonic  for  the  spasmo- 
philic diathesis,  was  determined  by  Mann2  and  Thiemich3  only  for 
the  age  of  eight  weeks.  From  this  it  follows  that  this  value  is  not 
to  be  regarded  as  a  limit  for  younger  infants,  at  least  not  for  the 
younger  prematures. 

In  the  majority  of  cases  the  disappearance  of  the  spasmophilic 
tendency  in  prematures  occurs  at  the  same  time  at  which  anemia 
and  craniotabes  begin  to  improve.  Thus  it  becomes  more  and 
more  apparent  that  the  three  symptoms,  anemia,  rachitis  and 
spasmophilia  are  in  a  certain  interrelationship.  It  may  very  well 
be  that  the  same  harmful  factors  that  damage  the  activity  of  the 
hematopoietic  organs  in  the  first  months  of  life  and  also  the  growth 

1  Ztschr.  f.  Kinderh.,  1919,  24,  1. 

2  Monatsschr.  f.  Psych,  u.  Neurol.,  1900,  7,  14. 

3  Jahrb,  f.  Kiaderh.,  1900,  51,  99,  222. 


SPASMOPHILIC  DIATHESIS  IN  PREMATURE  INFANTS     357 

and  the  normal  calcification  of  the  bones  in  such  a  high  degree 
produce  in  some  manner  unknown  to  us  changes  in  the  nervous 
system. 

Calcium  Metabolism.— A  calcium  deficiency  in  the  tissues  has 
been  demonstrated  by  numerous  investigators,  more  especially  in 
the  brain  and  blood.  The  earlier  investigations  on  the  blood  have 
more  recently  been  confirmed  by  Ilowland  and  Marriott,1  who 
found  the  calcium  of  the  blood  serum  to  be  low  in  this  condition, 
averaging  5.(>  mg.  per  100  cc  of  serum  in  a  group  of  18  cases,  the 
lowest  being  3.5  mg.  per  100  cc  of  serum,  the  average  normal 
amounts  being  10  to  11  mg.  per  100  cc.  They  found  a  normal 
calcium  content  in  the  serum  in  convulsive  disorders  due  to  other 
causes.  These  same  authors  found  the  magnesium  content  in  the 
serum  to  be  within  normal  limits  even  in  the  presence  of  active 
spasmophilia.  The  relation  of  calcium  to  the  symptoms  of  spasmo- 
philia has  been  studied  extensively,  especially  its  influence  on  the 
electric  excitability.  Physiologists  have  shown  that  certain 
mineral  ions  exert  a  specific  effect  on  muscle-nerve  irritability. 
Rosenstern2  and  Sedgwick3  reduced  the  electric  irritability  in  spasmo- 
philic infants  by  administering  large  doses  of  calcium  by  mouth. 
Loeb's4  findings  indicate  that  Na  and  K  increases  the  threshold 
for  excitation,  while  Ca  and  Mg  tend   to  decrease  this.    This 

Ca  +  Mg 
muscle  nerve  irritability  is  the  function  of  the  quotient  -v? —  .   ^ 

as  designated  by  Reiss.5  During  a  diarrhea  Holt6  has  demonstrated 
there  is  a  much  greater  loss  of  Na  and  K  than  Ca  and  Mg  in  the 
stools.  Diuresis  and  catharsis  often  cause  an  improvement  in  the 
spasmophilic  symptoms.  Consequently,  there  is  much  clinical 
and  experimental  evidence  that  spasmophilia  is  much  influenced 
by  the  relationship  between  the  Ca-Mg  and  Na-K  group  of  ions. 

Accidental  removal  of  the  parathyroid  gland  in  humans  and 
experimental  excision  of  these  glands  in  animals  have  both  resulted 
in  a  tetany  that  resembles  in  its  clinical  manifestations  the  spasmo- 
philia of  infants.  Following  the  animal  experiments  Howland 
and  Marriott7  have  demonstrated  a  diminution  in  the  calcium 
content  of  the  blood.  These  findings  have  been  verified  by  Mao- 
Callum  and  his  co-workers,8  who  also  found  a  decreased  calcium 
content  in  the  brain  and  an  increased  excretion. 

1  Quarterly  Jour.  Med.,  1917-1918,  11,  289. 

2  Jahrb.  f.  Kinderh.,  1910,  72,  154. 

3  St.  Paul  Med.  Jour.,  1912,  14,  497-519. 

4  Oppenheimer's  Handbuch  der  Biochemie. 
6  Ztschr.  f.  Kinderh.,  1911,  3,  1. 

6  Am.  Jour.  Dis.  Child.,  1915,  9,  213. 

7  Trans.  Am.  Ped.  Soc,  1916,  28,  200. 

8  MacCallum  and  Voegtlein:     Jour.  Exp.  Med.,  1909,  11,  118. 


358  DISEASES  PECULIAR  TO  PREMATURE  INFANTS 

Greemvald,1  in  his  experimental  studies,  found  that  the  phos- 
phorus excretion  in  the  urine  of  his  animals  was  greatly  decreased 
(to  as  low  as  8  per  cent  of  the  normal)  shortly  after  operation. 
He  also  found  an  increase  of  the  phosphorus  content  of  the  blood 
before  the  appearance  of  tetany.  There  was  also  a  sodium  and 
potassium  retention.  He  believes  that  following  the  extirpation 
of  the  parathyroid  there  is  a  decreased  excretion  through  the 
kidneys  and  an  abnormal  retention  in  the  tissues  of  the  alkali 
phosphates,  which  is  followed  by  a  decreased  retention  and  an 
increased  excretion  through  the  kidneys  as  soon  as  the  spasms 
develop. 

There  is,  however,  great  question  as  to  the  relationship  of  para- 
thyroid dysfunction  and  tetany  in  the  infant.  Pathological  studies 
lead  us  to  believe  that  parathyroid  lesions  in  infantile  tetany  are 
the  great  exception.  Parathyroid  lesions  have  been  described  in 
patients  who  have  shown  no  evidence  during  life  of  the  pathogno- 
monic findings  of  tetany. 

In  summarizing  the  pathogenesis  we  may  state  that  a  diminution 
of  the  calcium  salts  in  all  probability  is  the  most  important  factor 
in  the  development  of  this  condition.  However,  the  possibility  of 
an  absolute  or  relative  excess  of  the  sodium  and  potassium  salts, 
especially  the  phosphates,  playing  an  important  role  cannot  be 
overlooked.  The  relationship  of  disturbance  in  parathyroid  func- 
tions to  the  diminution  of  calcium  tissue  content  must  be  made  the 
subject  of  further  study  before  its  importance  can  be  fixed. 

Diagnosis.— The  differential  diagnosis  of  spasmophilic  convul- 
sions in  prematures  is  very  difficult.  Among  the  conditions  to  be 
considered  are  hydrocephalus,  congenital  syphilis  and  tuberculosis, 
epilepsy,  infections,  brain  injuries,  asphyxia  and  pulmonary  atelec- 
tasis. Tetanus  neonatorum  is  rarely  seen  today.  Meningitis  and 
encephalitis  are  the  most  important  of  the  infectious  processes,  and 
the  primary  focus  often  is  unknown.  Perhaps  the  best  test  after 
careful  history  and  physical  examination  is  the  determination  of 
the  electrical  reactions. 

It  must  not  be  forgotten  that  given  an  injured  brain  and  a  marked 
tendency  to  spasmophilia,  this  leads,  in  the  premature,  in  the  first 
place  to  convulsions  and  other  manifest  phenomena  of  this  diathesis. 

There  are  only  a  few  cases  in  the  literature  where  special  atten- 
tion has  been  devoted  continuously  from  birth  to  the  later  years 
to  the  condition  of  the  spasmophilic  infants.  Ylppo's  material 
enabled  him  to  fill  this  gap  to  a  certain  extent.  He  was  able 
to  show  positively  that  spasmophilia  in  premature  infants  very 
frequently  occurred  after  a  preceding  injury  to  the  brain,   and  this 

1  Jour.  Biol.  Chem...  1913,  14,  370. 


SPASMOPHILIC  DIATHESIS  IN  PREMATURE  INFANTS     359 

injury  rather  than  spasmophilia,  causes  the  later  brain  changes. 
Spasmophilic  convulsions  may,  however,  produce  extensive  damage 
to  the  brain,  and  may  result  in  various  defects  of  intelligence  and 
other  cerebral  disturbances. 

Treatment.— The  treatment  of  spasmophilia  is  largely  prophylac- 
tic and  embraces  the  therapy  of  rachitis  and  anemia  (see  p.  351). 
With  the  early  institution  and  the  continuation  of  these  hygienic, 
dietetic  and  medicinal  measures,  the  development  of  spasmophilic 
convulsions  will  be  very  unusual. 


Fig.    180. — Spasmophilia — double  fracture  of  both  forearms  following  prolonged 
carpal  spasm.     Premature,  aged  six  months. 

If  convulsions  appear  the  infant  must  be  kept  absolutely  quiet 
and  warm.  Narcotics  are  usually  employed,  the  best  being  chloral 
hydrate  0.25  to  0.5  gm.  per  rectum  and  calcium  bromide  0.5  to  1  gm. 
per  day. 

Lumbar  puncture  with  the  drawing-off  of  5  to  15  cc  of  spinal 
fluid  may  give  relief  from  repeated  convulsions. 

The  use  of  general  anesthesia  and  morphine  derivatives  to  control 
convulsions  is  to  be  avoided  except  as  measures  of  last  resort. 

Magnesium  sulphate  in  sterile  8  per  cent  solution  has  been 
used  in  subcutaneous  injections,  5  to  15  cc  repeated  once  or  twice 
within  forty-eight  hours,  to  control  convulsions.  Because  of  its 
marked  depressive  action  on  the  nervous  system,  the  infant  must 


360  DISEASES  PECULIAR  TO  PREMATURE  INFANTS 

be  very  closely  watched  for  collapse.  Although  this  method  has 
been  much  used  in  some  clinics  our  experience  has  not  warranted 
its  use  in  preference  to  our  preceding  measures. 

For  the  acute  manifestations  the  calcium  salts  in  maximal  doses 
(preferably  calcium  lactate,  0.3  to  0.6  gm.,  three  times  daily,  in 
solution  or  suspension)  in  our  experience  have  been  more  valuable 
than  the  magnesium  salts. 

Administration  of  cod-liver  oil  and  phosphorus  or  tricalcium 
phosphate  in  emulsion  of  cod-liver  oil,  as  recommended  in  the 
treatment  of  rachitis,  should  be  started  at  the  same  time  and  con- 
tinued indefinitely,  in  doses  varying  from  |  to  4  cc  twice  daily, 
dependent  upon  the  age  and  the  indications. 

Where  feeding  by  mouth  is  difficult,  catheter  administration 
must  be  resorted  to  together  with  inert  fluids  per  rectum.  If 
human  milk  is  not  obtainable  the  best  substitute  is  albumin  milk, 
which  is  poor  in  whey  and  rich  in  calcium.  Where  stimulating 
treatment  becomes  necessary  that  which  has  been  previously 
mentioned  may  be  employed. 

In  all  our  measures  extreme  gentleness  must  be  used,  as  any 
rough  handling  or  violence,  in  case  of  asphyxia,  has  a  very  harmful 
influence. 


PART  IV. 
THE  OUTLOOK  FOR  THE  PREMATURE. 


CHAPTER   XIX. 

PROGNOSIS. 

In  estimating  the  outlook  for  an  infant  born  before  the  natural 
termination  of  the  normal  period  of  pregnancy,  one  must  consider 
the  prenatal  and  the  postnatal  factors  before  arriving  at  a  conclu- 
sion. Of  prenatal  influences  the  most  important  is:  (1)  The 
absolute  age;  (2)  the  physiological  development  and  absence  of 
constitutional  anomalies;  (3)  transmitted  parental  conditions; 
(4)  the  presence  of  malformations.  Of  postnatal  conditions  the 
occurrence  of  any  of  the  various  diseases  of  the  new  born  affects 
the  prognosis  unfavorably  as  a  rule  while  the  temperature  and 
general  behavior  are  of  the  utmost  value  in  judging  of  its  chances 
for  life.  In  addition  to  these,  the  time  at  which  the  infant  is 
received  for  treatment,  and  the  character  of  the  treatment  it 
receives,  go  far  in  determining  the  probable  outcome.  While  all 
factors  must  be  taken  into  consideration,  yet  those  of  the  most 
practical  value  relate  to  the  child's  behavior.  Ability  to  nurse 
and  swallow,  coupled  with  strong  muscular  movements  and  a  good 
cry,  are  the  principal  indications  that  the  infant  possesses  a  fair 
degree  of  vitality  and  resistance  to  disease,  and  that  with  proper 
care  and  nourishment  it  stands  an  excellent  chance  of  resisting  the 
enemies  which  threaten  its  existence  during  the  first  few  weeks  of 
its  career,  namely,  cold  and  infection.  At  first  doubtful,  the  prog- 
nosis becomes  better  as  time  passes  in  proportion  to  the  care  the 
child  receives  with  respect  to  its  hygiene  and  feeding.  The  secret 
of  success  in  raising  the  premature  lies  in  avoiding  cold  and  infection, 
and  in  the  proper  selection  of  food  as  regards  quality,  quantity 
and  method  of  administration. 


362  PROGNOSIS 

There  is  not  the  slightest  doubt  but  that  the  premature  infant 
born  of  healthy  parents,  who  is  without  congenital  deformity  and 
who  survives  the  first  few  days  of  life,  is  entirely  capable  of  com- 
plete and  perfect  development.  The  various  factors  that  affect 
the  outlook  may  be  considered  in  detail. 

Age.— The  prognosis  of  the  premature  infant  depends  in  the  first 
place  chiefly  upon  the  actual  (fetal)  age,  or  in  other  words  upon  the 
length  of  time  it  has  remained  within  the  uterine  nest  (Pfaundler) ; 
the  infant  born  before  the  twenty-seventh  week  of  pregnancy 
having  but  a  slight  chance  of  living.  Other  things  being  equal, 
those  who  are  not  too  young  can  be  raised. 

The  influence  of  the  age  on  the  mortality  is  well  shown  by  the 
figures  of  Potel : 

Age.                                                     No.  of  children. 
65  fetal  months 56 

7  "  131 

7|  "  53 

8  "  110 

Sherman  quotes  the  figures  of  several  observers  and  includes 
those  of  his  own  experience  in  the  Children's  Hospital,  Buffalo: 


Number  dying. 

Per  cent. 

45 

80.4 

76 

58.1 

17 

30.1 

39 

35.5 

Incubator. 

Tarnier 

Charles 

SI 

sane  Hospital 

Gilbert 

Sherman 

Cook 

Per  cent. 

Per  cent 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Saved  at: 

6    months     . 

.      30 

10 

20 

0 

17 

6|        " 

20 

66 

20 

7 

.     63 

40 

71 

35 

50 

50 

71        " 
*  2 

75 

89 

66 

8 

.     85 

91 

85 

74 

8|        " 

.     95 

100 

Sherman's  table  shows  the  fallacy  of  the  popular  belief  that  more 
children  are  saved  at  the  seventh  month  than  at  the  eighth.  All 
things  being  equal  the  older  the  premature  the  better  its  chance  of 
life. 

Great  confusion  exists  in  a  study  of  various  statistics  because 
of  the  misapplication  of  the  term  "months";  the  latter  should 
apply  to  lunar  months  (twenty-eight  days)  and  not  calendar  months 
or  better  the  age  should  be  stated  in  days  or  weeks  to  avoid  all 
confusion. 

The  Germans  have  usually  considered  one  hundred  and  eighty- 
one  days  as  the  minimum  period  after  which  life  may  be  sustained, 
while  the  French  laws  regard  one  hundred  and  eighty  days  of  uterine 
life  as  necessary  to  viability.  That  one  hundred  and  eighty  days 
(six  and  one-half  lunar  months  or  nearly  twenty-six  weeks)  are 
necessary  to  existence  is  disputed  by  many. 


WEIGHT  363 

The  exact  age  of  an  infant  is  not  easy  to  determine.  In  fact, 
it  is  most  difficult,  due  to  the  uncertainty  as  to  the  beginning  of 
pregnancy.  As  previously  stated,  the  statement  of  the  mother  as 
to  her  last  menstrual  period  or  as  to  the  time  that  life  was  first  felt 
are  notoriously  uncertain,  and  weight,  length  and  other  head  and 
body  measurements  are  uncertain  factors  in  determining  the  degree 
of  unripeness  of  the  premature  child.  The  most  accurate  method 
at  hand  today  to  determine  the  age  of  the  premature  infant  is 
by  roentgenograms  of  the  skeleton,  since  the  osseous  development 
is  more  regular  and  offers  more  factors  for  consideration  than 
determining  the  age  based  on  length  and  other  measurements 
(see  "Skeletal  Development,"  p.  101). 

Weight.— This  is  a  much  less  dependable  factor  than  age  in  esti- 
mating the  outlook  for  the  premature  child.  All  conditions  being 
equal,  a  small  older  child  has  a  better  chance  of  living  than  a 
younger  one  who  weighs  more.  Nevertheless,  a  decrease  in  the 
death-rate  accompanies  an  increasing  birth  weight.  The  prognosis 
is  better,  on  the  face  of  it,  in  a  child  of  2000  gm.,  but  on  the  other 
hand,  the  2000-gm.  child  may  have  a  poorer  chance  of  life  because 
of  debility  (Pfaundler) . 

Crede  reported  a  mortality  of  83  per  cent  for  children  weighing 
1000  to  1500  gm.  and  11  per  cent  for  those  of  2000  to  2500  gm. 
weight.  Here  the  healthy  and  the  debilitated  prematures  have  not 
been  descriminated  between.  Separating  these  two  classes,  as 
Francois  did,  one  finds  that  of  81  children  born  of  diseased  parents, 
30  to  37  per  cent  died,  while  of  386  apparently  well  premature 
babies,  only  12.5  per  cent  died. 

Carlini  gives  as  the  lowest  figures  compatible  with  viability,  a 
weight  of  1000  gm.  and  a  length  of  31  cm.  These  figures  are  high 
as  attested  by  an  examination  of  the  literature,  where  several 
cases  are  on  record  as  surviving  with  either  a  weight  or  a  length 
smaller.     (See  list  of  smallest  prematures  saved.) 

Sherman,1  of  Buffalo,  published  the  following  table  showing  the 
number  of  children  saved  according  to  weight  in  his  institution: 

Percentage 
Weight.  saved. 

2  to  2\  pounds 25.0 

2|to3  " 50.0 

3  to3|        " 42.8 

3|  to  4  " 50.0 

4  to  4^        " 75.0 

1  Sherman,  D.-H.:  Buffalo  Med.  Jour.,  44,  053;  New  York  Med.  Jour.,  1905, 
82,  272. 


364  PROGNOSIS 

Cook's1  results  were  as  follows: 


No.  of  Percentage 

cases.  saved. 


Under  1500  gm 17  53 

1500  to  2000     "         20  55 

2000  to  2500     "         20  75 

Over  2500     "         5  100 

The  smallest  infant  to  survive  in  this  series  weighed  1250  gin. 
and  was  38  cm.  long.  The  initial  loss  was  130  gm. ;  it  began  to  gain 
on  the  fourth  day  and  had  regained  its  birth  weight  on  the  fifteenth 
day.  At  the  age  of  two  months,  which  otherwise  would  have  been 
at  term,  it  weighed  2000  gm. 

These  figures  indicate  that  the  heavier  the  child  at  birth,  the 
better  its  chances  of  surviving  the  first  few  weeks  or  months  of 
life.  What  bearing  the  natal  weight  has  on  the  future  of  the 
child  we  shall  see  later. 

The  smallest  prematures  recorded  in  the  literature  that  were 
saved  showed  the  following  body  weights  and  measurements: 

Author.*                                                                             Weight,  gm.  Length,  cm. 

Oberwarth1      ...             500 

J.  H.  Hess2  (71  days) 690 

(72  days) 740 

Oberwarth3 750                         35.3 

d'Outrepont4 750                         37.0 

Meyer5 750 

Roth6 750                         31.0 

Heller7 800 

840  32.0 

Ylppo 840 

L.  E.  Frankenthal .      .  850 

Pfaundler8 860                         35.5 

Waegeli9 860                         31.0 

Klinker10 895 

Ahlfeld11 900                         34.0 

Pizzini12 900                          30.0 

Jardine13 907 

Villemain14 950                          38.0 

Maygrier  and  Scwab16 970 

Heiberg16 975 

Rommel17 980 

Ahlfeld18 980                         37.0 

Tissier19 990                         31.0 

Schmid20 1000                         35.0  . 

Kopp21 1000 

J.  H.  Hess22 1070 

Reber23 1120 

1  Arch.  Ped.,  1921,  33,  201. 
*  References  will  be  found  on  page  376. 


TEMPERATURE  365 

Martha  and  Augusta  were  two  of  triplets  born  of  a  Greek  family 
at  six  and  a  half  months,  and  were  delivered  by  a  midwife.  The 
mother  visited  the  children  at  the  hospital  on  the  fourth  day  after 
their  birth  and  on  the  following,  the  fifth  day,  gave  birth  to  a  third, 
still-born  fetus  with  a  second  placenta,  and  was  again  out  on  the 
ninth  day.  Xo  less  interesting  were  some  of  the  deformities  in 
the  case  of  Baby  Martha  of  the  interesting  group  of  triplets.  She 
had  but  two  fingers  on  one  hand,  and  both  knees  and  elbows  were 
ankylosed  in  extension;  in  fact,  there  seemed  to  be  an  absence  of 
the  joint  surfaces;  while  Baby  Augusta  had  freedom  of  motion 
in  all  of  her  joints.  Considering  their  prematurity,  six  and  a 
half  months,  their  weight  at  birth,  740  and  090  gm.,  respectively, 
together  with  the  deformities  in  Baby  Martha,  it  is  surprising  to 
find  them  surviving  to  seventy-two  and  seventy-one  days,  when 
both  succumbed  during  attacks  of  cyanosis,  due  in  all  probability 
to  overfeeding. 

Because  of  Baby  Augusta's  better  development,  she  was  fed 
greater  quantities  from  the  start  and  although  she  did  not  have 
as  great  an  initial  fall  in  weight,  both  continued  to  lose  until  the 
twentieth  day,  Baby  Augusta  losing  a  total  of  200  gm.  and  Baby 
Martha  230  gm.  in  this  time.  The  records  are  rather  incomplete 
as  to  the  food  given  in  Case  II  during  this  period.  In  Case  I  the 
estimates  run  from  65  to  89  calories  per  kilo.  From  the  twentieth 
day  on  both  infants  showed  almost  stationary  weight  with  food 
values  below  120  and  the  greatest  gain  on  an  energy  quotient 
between  130  and  140;  and  death  in  both  cases  with  an  energy 
quotient  of  over  200. 

Temperature.— In  order  to  correctly  estimate  the  power  of  resist- 
ance of  a  premature  infant  it  is  necessary  to  consider  the  degree 
of  depression  of  the  temperature  and  with  it  the  weight  of  the 
child.  The  figures  of  Budin  show  that  the  lower  the  temperature 
the  more  serious  any  further  reduction  will  be,  and  the  less  the 
weight  the  more  easily  the  child  succumbs.  In  weaklings  in  whom 
the  temperature  was  32°  C.  or  less  (89.6°  F.)  the  mortality  was 
98  per  cent  when  they  weighed  1500  gm.  or  less;  97.5  per  cent 
when  they  weighed  between  1500  and  2000  gm.;  75  per  cent  when 
thev  weighed  more  than  2000  gm.  AVhen  the  rectal  temperature 
fluctuated  between  32°  and  33.5°  C.  (89.6°  and  92.3°  F.),  the 
mortality  of  the  first  group  was  97.3  per  cent;  of  the  second  group 
85.6  per  cent;  and  of  the  third  group,  weighing  2000  gm.  or  over, 
69.2  per  cent.  Thus  it  is  necessary  to  consider  both  the  weight 
and  the  degree  of  hypothermia.  The  most  striking  contrast  i- 
seen  in  comparing  the  figures  of  the  Maternite  and  the  Clinique 
Tarnier,  Paris.     To  the  former  are  often  brought  infants  with  a 


366 


PROGNOSIS 


Fig.  181. — Two  of  Greek  triplets  weighing  690  and  740  gm. 


Juue                          July                                                            August 

1J  20    23  2G  2D    2     5     8    11  14    17  20  23  2C    20    1      4      7     10  13  1G  19  22   25 

700 
600 

WEIGHT 
GM. 

500 

300 

FOOD  C.C.  200 

100 

- 

q_ 

-"- 

|    | 

u 

CALORIES  PER  KILO. 

1     W 

it:  +  113  1  u 

0 

13,6    |    1 

8 

i 

6 

Fig.  182. — Weight  and  food  curves  of  first  of  Greek  triplets.     Birth  weight,  690  grn. 


June 
1G  19  2 

July                                                                  August 
2  25  28    1     4      7     10  13  1G   19  22   25  28  31    3     6     9    12   15  18  21   24 

800 

700 

WEIGHT 

GM. 

COO 

500 
300 

FOOD  C.C.    200 

100 

— 

J-J 

i-- 

P- 

CALORIES  PER  KILO. 

1 

'• 

8 

,| 

I 

0 

1 

H 

1 

8 

1 

JO 

1 

%  +  1 

7 

Fig.  183. — Weight  and  food  curves  of  second  of  Greek  triplets.     Birth  weight,  740  gm. 


BODY  MEASUREMENT  367 

temperature  lowered  to  32°  C.  (89.6°  P\);  the  mortality  among 
these  neglected  weaklings  of  a  weight  of  2000  gm.  or  less  ranged  from 
90  to  98  per  cent.  At  the  Clinique  Tarnier  even'  precaution  is 
taken  to  conserve  the  body  warmth  and  here  the  mortality  of 
infants  of  the  same  weight  is  only  23  per  cent. 

Sherman's  experience  is  comparable  with  that  of  Tarnier.  Of 
10  babies  having  a  rectal  temperature  of  35.5°  C.  (90°  F.)  or  less, 
all  but  2  died. 

Porak  and  Durante  estimated  the  lowest  degree  to  which  the 
body  temperature  may  sink,  with  reparation  still  possible,  as 
follows: 

Infants  with  weight  less  than  110  gm.,  34°  C.  (93°  F.) 
Infants  with  weight  1100  to  1300  gm.,  30°  C.  (86°  F.) 
Infants  with  weight  1300  to  1750  gm.,  29°  C.  (84°  F.) 
Infants  with  weight  above  1750  gm.,  28°  C.  (82.4°  F.) 

Ylppo  disagrees  with  the  French  observers  in  that  his  belief  is 
that  the  mere  cooling  of  the  body  surface  does  not  result  in  death, 
but  that  many  of  these  infants  with  subnormal  temperature  are 
the  victims  of  birth  injuries  or  brain  hemorrhage,  the  latter  factors 
resulting  in  fatality. 

Apert  reported  a  premature  with  a  temperature  of  30°  C.  (86°  F.) 
which  lived.  Ylppo  states  that  he  has  seen  a  series  of  infants  who 
in  spite  of  a  temperature  of  only  27°  to  28°  C.  (80.6°  to  82.4°  F.) 
at  birth,  remained  alive.  If  the  subnormal  temperature  does  not 
persist  too  long,  with  resulting  capillary  damage  and  edema, 
especially  of  the  lungs,  recovery  is  possible.  To  show  the  relation 
between  mortality  and  subnormal  temperature,  Ylppo  summarizes 
his  material  in  the  table  on  page  368. 

Our  experience  has  been  that  unless  the  child  with  subnormal 
temperature  is  soon  placed  in  surroundings  more  favorable,  the 
prognosis  is  grave.  If,  when  placed  in  an  incubator,  the  resulting 
rise  of  temperature  is  retarded,  it  is  an  unfavorable  sign.  An 
abrupt  rise  after  a  previously  stationary  hypothermia  is  also 
unfavorable.  If  the  body  temperature  rises  to  37°  C.  (98.6°  F.) 
and  remains  there,  one  may  say  that  the  nervous  system  is  doing 
its  work  properly. 

Body  Measurements.— Other  measurements  beside  those  of  weight 
are  of  assistance  in   estimating  the  viability  of  the  premature. 


368 


PROGNOSIS 


TABLE    SHOWING    RELATION   BETWEEN    MORTALITY    AND    SUBNORMAL 
TEMPERATURE    IN    PREMATURES. 


37- 

35°  C.  (98.6-95°  F.). 

34.E 

-33°  C.  (95- 

J1.4°F.). 

No. 

Death  at : 

No. 

Death  at: 

5  days.           1  month 

5  days.            1  month. 

Group  I 

600  to  1000  gm. 

3 

2 
66.60% 

12 

8 
66.60% 

11 

91.60% 

Group  II    . 

1001  to  1500  gm. 

40 

10                  15 
25.00%         37.50% 

46 

15 
32.82% 

19 
41.30% 

Group  III  .      .      .      . 
1501  to  2000  gm. 

76 

7                  16 
9.12%         21.05% 

40 

3                    8 
7.50%         20.00% 

Group  IV  .... 
2001  to  2500  gm. 

4 

85 

4                     5 

4.71%          5.88% 

19 

1                    5 
5.26%         26.32% 

32.9 

-31°  C.  (91°-87.8°  F.l. 

30.9° 

29°  C.  (87.6-84.4°  F.). 

Group  I 

600  to  1000  gm. 

5 

4 
80.00% 

5 
100.00% 

6 

5 
83.30% 

Group  II    ...      . 
1001  to  1500  gm. 

27 

7 
25.90% 

13 

48.10% 

12 

7 
58.30% 

10 
83.30% 

Group  III  .      .      .      . 

1501  to  2000  gm. 

20 

5 

25.00% 

10 
50.00% 

12 

2 
16.60% 

7 
58.30% 

Group  IV  ...      . 

2001  to  2500  gm. 

8 

> 

25.00% 

1 

28.9°- 

-27°  C.  (84.2°-80.6°  F.). 

26.9C 

-25°  C.  (S0.4°-77o  F.). 

Group  I 

600  to  1000  gm. 

6 

5 
83.30% 

6 

100.00% 

1 

1 
100.00% 

Group  II    ...      . 
1001  to  1500  gm. 

7 

3 

42.80% 

6 
85.70% 

1 

1 

100.00% 

Group  III  .... 
1501  to  2000  gm. 

5 

2 
40.00% 

3 

60.00% 

Group  IV  ...      . 
2001  to  2500  gm. 

5 

1 
20.00%, 

1 

1 
100.00% 

CAUSE  OF  LABOR 


369 


Ostrcil  gives  figures  which  show  a  rapid  lessening  of  mortality  in 
infants  weighing  over  2000  gm.  and  of  a  length  greater  than  44  cm.: 

Weight.  Viability. 

Grams.  Per  cent 

1400 0 

1500 0 

1600 17 

1700 27 

1800 21 

1900 33 

2000 47 

2100 50 

2200 43 

2300 49 

2400 58 

2500 54 

2600 62 

2700 59 

2800 63 

Length.  Viability. 

Cm.  •  Per  cent 

40 21 

41 20 

42 25 

43 28 

44 51 

45 50 

46 55 

47 58 

Similarly  Pfaundler  demonstrated  the  decreasing  mortality  with 
increasing  birth  weight: 


Body  weight. 

Body 

length, 

cm. 

Mortality  in 
first  weeks 

of  life, 
per  cent. 

Age  in  fetal 
months. 

Normal 

fetuses, 

gm. 

Prematures, 
gm. 

Surviving, 
per  cent. 

6 

6.5 

7 

7.5 

8 

1300 
1800 
2500 

1000 
1200 
1500 
1800 
2200 

35 
37 
39 
42 
45 

95                        5 
82                    18 
63                    37 
42                    58 
20                    80 

The  Cause  of  Labor.— Generally  speaking,  in  those  infants  whose 
early  birth  depends  upon  the  induction  of  labor,  the  outlook  is 


24 


370  PROGNOSIS 

better   than   when    it   results   from    spontaneous   delivery.    The 
following  percentages  are  given  as  saved  after  induced  labor: 


Born  alive  Saved, 

Author.                                                                                      per  cent.  per  cent. 

Hahl 75.0  59.5 

Raschkow 84.8  78.6 

Heymann 71.2 

Ahlfeld 90.9 

Lorey 74.0  60.0 

Hunziken 83.5 

Ostrcil 56.9 


That  there  are  exceptions  to  the  above  statement  cannot  be  doubted. 
For  example,  the  occurrence  of  albuminuria  may  lead  to  the  induc- 
tion of  labor,  the  child  being  not  only  premature  but  a  weakling 
with  low  weight  and  vitality.  On  the  other  hand  the  infant  born 
as  a  result  of  the  shock  attendant  upon  operative  interference  in 
non-suppurative  appendicitis  would  in  all  probability  possess 
excellent  vitality.  The  artificial  induction  of  premature  labor 
with  its  associated  trauma  to  the  infant  plays  a  very  important 
part  in  the  mortality.  The  foregoing  figures  are  to  be  seriously 
questioned  as  there  is  no  record  of  the  birth  weight,  which  in  many 
instances  was  undoubtedly  well  above  3000  gm.  and  therefore  not 
strictly  applicable  to  the  premature  infant. 

Prenatal  Influences.— The  health  of  the  mother  during  the  period 
of  gestation  is  of  the  utmost  importance  in  prognosticating  the 
immediate  future  of  the  premature  and  the  weak.  The  occurrence 
of  syphilis,  tuberculosis,  alcoholism,  eclampsia,  nephritis,  severe 
heart  disease,  or  other  conditions  producing  faulty  nutrition  of  the 
fetus— all  have  their  effect  on  the  well-being  of  the  infant.  Of 
special  importance  is  the  occurrence  of  syphilis  or  nephritis. 
Though  necessarily  the  age  and  weight  of  the  child  have  a  direct 
bearing  upon  its  physiological  development,  yet  the  occurrence  of 
constitutional  diseases  in  the  child  is  even  of  greater  importance. 
Despite  the  greater  age  and  the  comparatively  good  development 
of  a  premature,  the  existence  of  a  prenatal  syphilitic  infection  or  of 
an  inherited  predisposition  to  tuberculosis  greatly  jeopardizes 
the  prognosis.  If  constitutionally  well,  the  infant  under  1000 
gm.  weight  can  live,  providing  sufficient  attention  is  paid  to  the 
three  conditions  governing  the  survival  of  these  infants.  On  the 
other  hand,  prematures  or  even  full-term  infants,  the  victims  of 
parentally  derived  disease,  often  do  not  survive,  regardless  of  the 
care  they  receive. 

Francillon  attempted  to  group  the  prematures  in  relation  to  the 


PRENATAL  INFLUENCES 


371 


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372  PROGNOSIS 

cause  of  the  prematurity  and  to  show  the  death-rate  for  each 
group.  He  considers  as  premature  all  infants  born  with  a  weight 
below  2900  gm.  Of  2271  births,  832  were  premature,  a  proportion 
of  about  36  per  cent.  Of  these  832  prematures  the  number  born 
dead  was  76,  a  still-born  death-rate  of  9.1  per  cent.  Of  these  76  born 
dead,  59  died  in  utero.  The  rest  died  during  labor  either  as  the 
result  of  accident  or  of  mutilating  operations.  Of  756  born  alive, 
39,  or  5.1  per  cent,  died  during  their  stay  in  the  maternity  depart- 
ment, that  is,  during  the  first  three  weeks  of  their  existence.  In 
grouping  them  according  to  the  cause  of  the  prematurity,  Francillon 
finds  that: 

Because  of  obstetrical  intervention:  6  out  of  28  cases  died  (21.4 
per  cent). 

Because  of  twins:  5  out  of  49  cases  died  (14.2  per  cent). 

Because  of  albuminuria:  3  out  of  23  cases  died  (13  per  cent). 

Because  of  syphilis:  8  out  of  75  cases  died  (10.6  per  cent). 

Because  of  heart  disease:   1  out  of  13  cases  died  (7.7  per  cent). 

Because  of  unknown  causes:  13  out  of  499  cases  died  (2.7  per 
cent) . 

Ylppo,  discussing  the  various  factors  which  are  concerned  with 
the  etiology  and  mortality  of  prematurity,  presents  the  table  on 
p.  371. 

Deformities.— Certain  deformities  affect  very  materially  the  well- 
being  of  the  premature  child  and  not  infrequently  are  important 
factors  in  the  causation  of  labor  before  term.  One  of  the  most 
important  compatible  with  life  is  cleft  palate,  either  with  or  without 
hare-lip. 

There  are  some  features  which  are  especially  noteworthy.  Of 
the  668  cases,  more  than  half,  369,  were  due  to  unknown  causes, 
which  probably  could  have  been  explained  by  mild  disorders  or 
malpositions  of  the  uterus.  The  prognosis  in  tuberculosis  is  much 
better  than  in  lues— a  mortality  of  33.33  per  cent  in  the  former 
as  contrasted  with  73  per  cent  in  the  latter.  Acute  infections  of 
the  mother  do  not  often  appear  in  the  premature,  but  are  very 
important  in  bringing  about  premature  delivery.  Infants  born  of 
eclamptic  and  nephritic  mothers  have  a  very  high  mortality  because 
of  the  fact  that  labor  is  shortened  and  often  artificially  induced, 
so  that  death  most  often  results  from  the  damage  incidental  to 
delivery.  Diabetes  and  cardiac  decompensation  have  a  very 
deleterious  effect  on  fetal  development.  The  birth  of  twins  is 
closely  linked  with  prematurity  and  in  Ylppo 's  series  this  class 
was  19.2  per  cent  of  the  total  (128  of  668  cases). 

Interference  with  the  proper  taking  of  nourishment  complicates 
an  already  difficult  problem,  that  of  feeding,  and  impairs  the  child's 
chances  of  living.    Of  other  deformities,  atresias  of  the  digestive 


OTHER  DISEASES  OF  THE  NEW-BORN  PREMATURE        373 

tract  are  not  uncommon  and  generally  speaking  offer  an  absolutely 
bad  prognosis  unless  limited  to  the  rectum  and  anus. 

Illegitimacy.— Bakker  paid  attention  to  this  phase  of  the  birth 
of  premature  infants  born  in  the  Eppendorfer  Hospital,  Hamburg, 
from  1907  to  1912.  Of  one  group  weighing  from  2000  to  2500  gm., 
80  per  cent  of  the  legitimate  children  survived  for  at  least  one  year, 
while  of  the  illegitimate  only  61.3  per  cent  lived  that  long.  Thus 
the  mortality  in  the  illegitimate  is  seen  to  be  almost  twice  as  high 
as  in  the  legitimate  of  the  same  weight.  Of  those  weighing  from 
1500  to  2000  gm.  the  mortality  among  the  legitimate  was  30  per 
cent,  among  the  illegitimate  about  47  per  cent.  Of  a  group  of  75 
weighing  from  1000  to  1500  gm.  only  10  lived  to  leave  the  institu- 
tion. Four  of  these  were  followed  up,  of  which  only  one,  a  legitimate 
child,  was  alive  at  the  end  of  the  year. 

Thus  we  see  that  the  death-rate  among  the  illegitimate  born 
ranges  from  half  again  to  twice  as  high,  or  even  higher,  than  in  the 
legitimate,  depending  upon  the  weight  at  birth.  This  difference  is 
accounted  for  largely  by  the  inferior  care  the  illegitimate  infant 
receives  at  the  most  critical  period  of  its  existence,  the  first  few 
days  after  birth. 

Infectious  Diseases.— The  secret  of  success  in  raising  premature 
infants  lies  in  three  directions:  (1)  In  the  prevention  of  chilling 
of  the  body  surface  with  the  production  of  a  subnormal  tempera- 
ture; (2)  in  the  administration  of  the  proper  diet;  (3)  in  the  pro- 
phylaxis against  infectious  diseases. 

Of  the  commoner  infections  erysipelas  results  fatally  in  the 
majority  of  cases.  It  is  usually  violent  in  its  course  in  the  very 
young  and  is  frequently  accompanied  by  signs  of  cardiac  failure. 
The  prognosis  of  tetanus  neonatorum,  fortunately  now  very  rare, 
is  generally  unfavorable,  even  worse  than  with  older  children. 
In  ophthalmia  neonatorum  the  outlook  is  good  when  proper  treat- 
ment is  instituted  sufficiently  early.  In  sepsis  the  prognosis  is 
bad,  varying  in  direct  proportion  with  the  age  and  the  immaturity 
of  the  infant  attacked.  The  greater  the  number  of  organs  involved 
the  poorer  the  child's  chances.  In  gastro-intestinal  and  other 
visceral  hemorrhages  as  well  as  in  other  varieties  of  bleeding  in  the 
premature  new  born,  the  outlook  depends  upon  the  underlying 
cause  or  disease;  sepsis,  syphilis,  asphyxia,  etc.;  but  in  general,  it 
is  grave,  even  more  so  as  a  rule  than  the  underlying  condition  when 
uncomplicated. 

Other  Diseases  of  the  New-born  Premature.  —  Icterus  of  the  new 
born,  unless  due  to  atresia  of  the  biliary  passages,  offers  a  favorable 
prognosis  and  is  not  followed  by  complications.  Recovery  usually 
occurs  from  moist  gangrene  of  the  cord  unless  the  infection  spreads 
to  adjacent  parts.     Only  in  the  very  weak  are  umbilical  ulcers 


374  PROGNOSIS 

followed  by  extensive  tissue  destruction.  Inflammations  of  the 
umbilical  cord,  usually  seen  in  the  very  feeble,  of  necessity  offer 
a  poor  prognosis.  A  rteritis  has  a  comparatively  favorable  outlook, 
but  umbilical  phlebitis  is  almost  invariably  fatal. 

General  Conditions.— Of  all  prognostic  signs,  the  study  of  the 
general  condition  of  the  premature  infant  offers  the  best  evidence 
of  the  child's  viability.  If  it  cries  strongly,  exhibits  vigorous 
movements,  tends  to  stay  awake  and  possesses  well-developed 
ability  to  nurse,  its  viability  may  be  considered  as  established  and 
its  opportunity  for  maintaining  life  good.  On  the  other  hand,  if 
there  is  a  tendency  to  deep  sleep,  to  apathy,  to  asphyxia  and 
cyanosis  or  to  hypothermia,  if  the  nursing  ability  is  poor  and 
there  is  difficulty  in  swallowing,  the  outlook  is  bad  for  the  infant. 
Sometimes  several  days  of  observation  are  necessary  in  order  to 
pass  judgment  upon  the  viability. 

The  condition  of  the  turgor  of  prematurely  born  infants  is  of  con- 
siderable importance  as  a  prognostic  sign.  Absolutely  flabby  pre- 
matures with  a  poor  turgor  and  a  poor  tonus  prove  to  be  lost  in 
almost  all  cases.  Prematures  with  a  good  turgor  and  a  good  tonus, 
even  with  a  low  weight,  almost  always  live  up  to  expectation.  It 
is  highly  probable  that  the  tissue  turgor  is  conditioned  by  the 
mode  in  which  the  water  is  held.  Where  the  water  content  is 
diminished  the  turgor  decreases.  The  presence  of  water  is  closely 
connected  with  the  presence  of  alkalies  in  the  tissues  and,  therefore, 
it  might  be  correct  to  state  the  hypothesis  that  the  alkali  deficiency 
of  the  prematurely  born  leads  to  a  poor  tissue  turgor  and  therefore 
to  inability  to  live  (Langstein). 

The  greatest  number  of  premature  children  die  in  the  first  few 
days  of  life.  This  is  because  of  birth  trauma,  the  unfinished 
condition  of  the  organs,  or  the  result  of  postpartum  conditions  or 
constitutional  diseases  or  lack  of  facilities  for  proper  care.  At 
autopsy  the  cause  of  death  is  often  not  to  be  found,  although 
the  unripeness  of  the  infant  is  evident. 

Although  1000  gm.  is  accepted  as  nearly  the  low  weight  compat- 
ible with  life,  exceedingly  small  babies  may  live  and  thrive  as  is 
attested  by  the  cases  previously  listed  on  page  44  (Physiology). 

GENERAL  MORTALITY. 

A  consideration  of  the  preceding  factors,  prenatal  and  post- 
natal, forms  the  basis  for  the  mortality  statistics  which  have  been 
compiled  by  Ylppo  in  a  series  of  over  a  thousand  premature  infants. 

The  above  figures  are  quite  accurate  to  the  first  year.  Beyond 
this  it  was  difficult  to  follow  the  patients.  However  only  about 
70  of  the  series  could  be  followed.     Of  the  668  prematures  320,  or 


GEXERAL   MORTALITY 


375 


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376  PROGNOSIS 

53.5  per  cent,  died.  About  50  per  cent  survived  to  one  year. 
An  interesting  feature  is  the  fact  that  the  mortality  after  the  first 
year  fairly  well  approximates  that  of  full-term  children.  In  the  first 
to  the  fifth  day  of  life  the  greatest  death-rate  is  noted  and  is  linked 
with  the  damage  to  the  infant  in  the  course  of  labor. 

Because  of  the  fact  that  the  etiological  factors  in  the  birth  of 
twin  prematures  differs  greatly  from  those  of  single  birth  (usual 
absence  of  infectious  and  constitutional  disorders  in  the  mother), 
Ylppo  considers  this  class  separately: 

The  table  shows  that  at  the  end  of  the  first  year  the  total  mor- 
tality was  37.07  per  cent,  considerably  less  than  with  single  births. 


REFERENCES. 

1.  Jahrb.  f.  Kinderh.,  n.  f.,  60,  377  and  short  reports. 

2.  A  Study  of  the  Caloric  Needs  of  Premature  Infants,  Am.  Jour.  Dis.  Child., 
1911,  2,  302-314. 

3.  Oberwarth:     Ergebn.  d.  inn.  Med.  u.  Kinderh.,  1911,  7,  191. 

4.  d'Outrepont:     Abhandlungen  und  Beitrage  geburtshilflichen  Inhalts,  Parti, 
p.  167. 

5.  Miinchen.  med.  Wchnschr.,  1912,  No.  47,  p.  2596. 

6.  Roth:     Ztschr.  f.  Kinderh.,  1913,  5,  134. 

7.  Heller:     Munchen.  med.  Wchnschr.,  1912,  No.  47,  p.  2596. 

8.  Munchen.  med.  Wchnschr.,  1907,  No.  29,  p.  1417. 

9.  Gynaecologia  Helvetica,  1917,  autumn  edition,  p.  199. 

10.  Allgemeine  deutsche  Hebammenzeitung,  1903,  p.  289. 

11.  Lehrbuch  der  Geburtshitfe,  3d  edition,  1903,  p.  214. 

12.  L'arte  ostetrica,  November,  1908. 

13.  Cited  by  Mansell:    British  Med.  Jour.,  1902,  1,  773. 

14.  Nouvelles  Archives  d'Obstetrique  et  de  Gynecologic  1895,  Repertoire,  No.  2, 
p.  50. 

15.  Bulletin  de  la  Societe  Obstetr.  de  Paris,  1907,  p.  216. 

16.  Monatsschr.  f.  Geb.  u.  Gynak.,  17,  369. 

17.  Munchen.  med.  Wchnschr.,  1903,  No.  37,  p.  1603. 

18.  Lehrbuch.  d.  Geb.,  1903,  3d  edition,  p.  214. 

19.  Zentralbi.  f.  Gynak.,  1912,  No.  19,  p.  626. 

20.  Allgem.  Deutsche  Hebammenzeitung,  1911,  No.  11,  p.  235. 

21.  Schmidt's  Jahrbiicher,  3,  128. 

22.  Unreported  case. 

23.  The  Prematurely  Born,  Cor.-Bl.  f.  schweiz.  Aerzte,  Basel,  1918,  No.  27,  48, 
897. 


CHAPTER    XX. 
THE  FUTURE  OF  THE  PREMATURE  INFANT. 

The  early  small,  thin  face  with  its  mass  of  wrinkles  in  the  presence 
of  proper  feeding  soon  becomes  rounded  out  by  the  deposit  of  layers 
of  fat,  the  skin  becomes  smoother  and  the  face  more  nearly  like  thai 
of  a  normal  nursling.  There,  however,  remains  for  a  more  or  less 
indefinite  period  a  prominence  of  the  sucking  cushions  greater  than 
that  seen  in  the  normal  infant.  The  enlargement  of  the  tongue  may 
be  noted  until  toward  the  end  of  the  first  year.  The  same  may  be 
true  of  exophthalmos.  The  small  stumpy  nose  may  also  retain  its 
characteristic  appearance  until  the  end  of  the  first  year.  The 
"doll"  type  of  face  is  also  usually  present  until  after  the  fourth 
or  sixth  month  of  life. 

The  infants  often  show  the  adenoid  appearance,  due  to  the  small 
nose,  with  its  tendency  to  the  development  of  a  posterior  rhinitis, 
and  the  large  tongue.  This  appearance  is  lost  as  the  megacephalus 
disappears. 

The  other  characteristic  physical  changes,  which  are  evidenced 
by  a  short  neck,  a  long,  broad  trunk,  with  a  deeply  seated  navel 
and  short  legs,  and  which  can  usually  be  noted  by  the  second  to  the 
fourth  month  of  life,  gradually  disappear  during  the  second  year. 

The  question  is  often  asked  as  to  what  is  the  ultimate  outlook 
for  prematurely  born  infants  who  live  beyond  the  first  year  of  life. 
It  is  desired  to  know  (1)  if  they  suffer  from  a  higher  mortality  in 
early  childhood  than  the  full-term  infant,  and  (2)  are  those  that 
survive  normal  mentally  and  physically.  In  order  to  answer  these 
questions  in  the  proper  way  it  is  necessary  to  observe  the  children 
over  a  period  of  years.  With  institutional  children  this  is  often 
impossible  and  even  in  private  practice  difficult.  Usually  one 
must  satisfy  himself  with  comparisons  at  the  end  of  the  first  year. 
For  this  comparison  the  full-term  normal  child  is  used  as  a  basis, 
but  as  Pfaundler  says,  only  those  who  have  been  similarly  fed 
and  raised  under  the  same  hygienic  conditions  can  be  fairly  con- 
trasted. 

One  observes  with  the  premature  as  with  the  full-term  child  that 
the  breast-fed  infants  raised  among  good  home  surroundings  have 
a  lower  mortality  than  the  same  in  institutions,  and  that  the 
artificially  fed  have  a  greater  mortality  than  the  breast  fed. 


378 


THE  FUTURE  OF  THE  PREMATURE  INFANT 


Ostrcil  gives  the  statistics  from  the  Prague  Maternity. on  1542 
illegitimate  prematures.  The  total  mortality  of  these  infants  was 
52.7  per  cent.-  Of  these  cases  814  were  followed  for  nine,  ten  and 
eleven  years.  Of  this  series  86. G  per  cent  are  living,  but  these  figures 
include  those  in  whom  there  was  no  indication  of  syphilis,  those 
who  received  breast  milk  after  leaving  the  institution,  and  those 
weighing  up  to  2800  gm.  Those  under  2500  gm.  weight  and  45  cm. 
length,  who  left  the  institution  alive  and  had,  therefore,  survived 
the  first  weeks,  were  86  in  number,  of  which  38  were  boys  and  48 
girls.  Of  these  51  were  alive  at  the  end  of  the  first  year,  23  boys 
and  28  girls,  a  mortality  of  40.7  per  cent,  or  39.5  per  cent  for  males 
and  41.7  per  cent  for  females. 

Oberwarth's  results  are  shown  in  tabulated  form  below.  He 
followed  for  more  than  a  year  12  infants  who  weighed  less  than 
2000  gm.  and  who  were,  with  2  exceptions,  illegitimate  and  raised 
under  poor  hygienic  surroundings. 


Entrance. 

Latf 

>r  examination. 

General  physical 
development. 

Length, 

Weight, 

Age. 

W  eight, 

Length, 

Mentality. 

cm. 

gm. 

gm. 

cm. 

46.0 

1880 

17  mos. 

10,750 

79 

Good;  has  eight  teeth, 
walked  at  fifteen  mos. 

Normal. 

43.6 

1890 

17    " 

10,250 

77 

Walks  alone 

Normal. 

43.3 

1960 

24    " 

9,700 

75 

Good ;  has  twelve  teeth ; 
walked  at  fifteen  mos. ; 
has   a   congenital  hip 

Very  good. 

dislocation 

41.5 

1460 

30    " 

9,750 

77.6 

Rachitis;  anemia;  con-    Normal, 
genital  hip  dislocation 

40.0 

1750 

40    " 

10,900 

80 

Severe      rachitis;      not   Backward, 
walking 

44.0 

1820 

54    " 

15,000 

95 

Very  good                             Very  good. 

41.5 

1710 

60    " 

10,900 

86 

Anemia;      large     head;    Good. 

convulsions 

1250 

66    " 

13,900 

103 

Flat  occipital  region 

Fair. 

44.2 

1980 

6.5  yrs. 

14,400 

101 

Anemic                                 Nervous. 

42.5 

1710 

6.5     " 

17,000 

106 

Anemic  for  eleven  mos. ;    Normal, 
now  100  per  cent  hem- 
oglobin 

41.0 

1500 

6.8     " 

16,700 

109 

Rachitic  deformities          Backward. 

45.5 

1950 

8.2     " 

21,300 

123 

Good                                     Normal. 

A  comparison  of  these  results  with  those  attained  with  a  similar 
group  of  full-term  infants  reflects  with  credit  on  the  future  develop- 
ment of  the  premature.  The  tendency  to  anemia  and  the  results 
of  rachitis,  to  both  of  which  the  premature  is  frequently  subject, 
are  not  uncommonly  seen  in  the  early  years  of  childhood.     Whether 


77/ E  F  VT  l 'RE  OF  THE  PRE M. \  T  (  HE  I X I •'.  1  .V T  379 

the  lack  of  resistance  is  a  result  of  the  shortening  of  the  period  of 
intra-uterine  nutrition,  or  whether  it  is  due  to  extra-uterine  factors, 
more  especially  underfeeding  and  improper  care  during  infancy 
cannot  be  stated,  but  we  are  inclined  to  believe  that  the  former 
factor  outweighs  the  latter. 

According  to  Feer,  many  infants  overcome  their  handicaps  and 
make  good  progress,  so  that  by  the  end  of  the  second  or  third  year 
their  measurements  are  about  the  same  as  those  of  the  normal  child. 
Some,  however,  do  not  do  as  well  as  this,  showing  tendencies  to 
rachitis,  spasmophilia  and  especially  anemia.  The  pallor  develop- 
ing toward  the  end  of  the  first  year  depends  in  many  instant  es  upon 
the  lack  of  iron  deposits  which  are  made  in  great  part  during  the 
last  few  months  of  intra-uterine  life;  in  other  instances  it  depends 
upon  a  lack  of  development  of  the  blood  making  organs. 

Wallich  and  Fruhinsholz  analyzed  the  previous  history  of  older 
children  and  adults  and  also  ascertained  the  later  history  of  the 
prematurely  born.  Possibly  the  earliest  instance  of  prematurity  on 
record  is  that  of  the  Professor  at  Padua  who  was  born  at  the  end 
of  the  seventh  month  and  lived  to  be  eighty.  Other  famous  pre- 
matures include  Newton,  Rousseau,  Voltaire,  Cuvier,  Victor  Hugo, 
Lamartine  and  Renan. 

The  outlook  for  the  future  of  the  premature  is  shown  to  depend 
in  a  large  measure  upon  the  degree  of  development  at  birth,  as 
evidenced  chiefly  by  the  weight.  Of  17  infants  weighing  between 
900  and  1500  gm.,  studied  by  Wallich  and  Fruhinsholz,  41.1  per 
cent  developed  into  normal  adults,  a  similar  percentage  were 
but  slightly  handicapped,  while  the  balance  were  much  below 
normal.  Of  the  26  weighing  between  1500  and  2000  gm.,  52  per 
cent  were  normal  and  3G  per  cent  slightly  handicapped.  Of  the 
36  between  2000  and  2500  gm.,  75  per  cent  were  normal  and  22.2 
per  cent  retarded.  The  last  group  comprised  (15  weighing  from 
2500  to  3000  gm.  of  which  78.4  per  cent  were  normal  and  20  per 
cent  somewhat  under  the  normal. 

The  same  authors  traced  back  to  birth  the  history  of  180  children 
from  Broca's  surgical  clinic  and  620  inmates  of  the  asylum  for  the 
epileptic  and  feeble-minded.  Twelve  per  cent  of  the  former 
and  S  per  cent  of  the  latter  were  known  to  be  of  premature  birth. 
Thus  we  see  that  a  large  percentage  of  the  prematurely  born  develop 
normally  in  both  mind  and  body,  while  the  balance  exhibit  varying 
degrees  of  inferiority,  hernias,  club  feet,  enuresis,  pavor  nocturnus, 
etc.  These  signs  of  degeneracy  are  seemingly  the  result  of  the 
prematurity  and  of  the  trauma  sustained  at  the  time  of  delivery. 

The  studies  of  Ylppo  on  the  development  of  the  premature  from 
infancy  to  the  school  age  led  him  to  make  certain  generalization-. 


380  THE  FUTURE  OF  THE  PREMATURE  INFANT 

The  growth  of  premature  infants  (those  with  a  weight  below  2500 
gm.)  discloses  a  considerable  derangement  in  the  first  three  to  five 
years  of  life.  This  discloses  itself  in  that  the  weight,  length,  skull 
and  thorax  growth  in  almost  all  this  class  is  slower.  This  retarda- 
tion in  growth  is  the  more  marked,  the  less  the  body  weight  and 
length. 

Growth  disturbances  appear  immediately  after  birth  and  are 
proportionately  more  marked  in  the  first  six  to  twelve  extra-uterine 
months  of  life,  t  At  the  age  of  two  to  four  years  there  begins  a  gradual 
equalization,  wThich  in  most  instances  ends  at  about  five  or  six  years. 
From  this  period  on  the  curves  of  growth  are  parallel  with  those  of 
full-term  children.  Only  in  the  case  of  very  small  prematures  with 
a  birth  weight  of  1000  gm.,  the  reparation  does  not  seem  to  be 
completed  by  the  age  of  five  to  six  years.  The  growth  in  length 
is  up  to  this  time  disturbed  approximately  to  the  same  extent  as  the 
mass  growth.   • 

The  chest,  which  is  proportionately  deficiently  developed  in 
prematures,  also  shows  on  the  average,  until  the  age  of  three  years 
a  retardation  in  growth.  In  the  years  following,  the  breast  circum- 
ference, however,  reaches  practically  the  same  value  as  in  full-term 
children  of  a  similar  age..  The  cross-section  of  the  chest  of  the 
premature  approaches  more  the  form  of  an  ellipse  than  a  circle. 
The  cross-section  area  is  in  the  smallest  prematures  strikingly  small 
in  comparison  with  the  body  length.  The  growth  of  the  head  is 
the  least  disturbed  or  retarded.  This  is  explained  by  the  fact  that 
the  brain  growth  in  premature  follows  certain  individual  laws 
without  depending,  as  a  rule,  on  the  development  of  the  body, 
i  The  principal  point  of  these  growth  disturbances  in  the  prema- 
ture is  immaturity.  The  more  immature  an  infant  is  born,  the 
more  deficient  is  the  function  of  the  various  organs  in  extra-uterine 
life.  Especially  in  the  province  of  digestion  are  variations  noted 
in  prematures,  because  of  poor  utilization,  particularly  of  fat  and 
salts,  a  qualitative  undernourishment  results  which  favors  the 
development  of  growth  disturbances. 

Besides  these  and  other  exogenous  factors,  certain  endogenous 
factors  probably  play  a  passing  but  noteworthy  part  in  the  pro- 
duction of  growth  disturbances.  All  these  defects,  however,  gradu- 
ally disappear  or  are  overcome,  so  that  reparation  is  completed 
by  the  time  the  premature  reaches  the  school  age.  From  this  time 
on  the  growth  again  turns  back  to  the  paths  which  have  been 
designed  for  the  hereditary  body  mass  of  the  child. 

Ylppo  was  able  to  follow  up  89.52  per  cent  of  his  cases  and  thus 
compiled  his  figures  for  the  mortality  and  future  development  of 
the  premature. 


THE  FUTURE  OF  THE  PREMATURE  INF  AST 


381 


INFANTS    WITH    A    BIRTH   WEIGHT   UP   TO   2500    G.M.    IN'    THEIR 
FIRST   EIGHT   YEARS. 


Year  of  birth. 

Total 
No. 

Not  followed 

up 

per  cent. 

Followed 
through. 

In  1918 
at  end 

of  year 
of  life. 

Of  these 
still  alive 
per  cent. 

Of  these 

dead, 
per  cent. 

1918         .      . 

48 

48 

i 

3 

16  = 

32.65 

33 

=  67.35 

1917         .      . 

57 

2 

=     3.51 

55 

1 

35  = 

63.64 

20 

=  36.36 

1916         .      . 

98 
90 

3 
5 

=    3.06 

=     5.56 

95 

85 

2 

46  = 

4^.42 

49 
43 

=  51.58 

1915         .      . 

3 

42  = 

49.41 

=  50.59 

1914         .      . 

101 

11 

=  10.89 

90 

4 

40  = 

44.44 

50 

=  55.56 

1913         .      . 

85 
83 

13 
10 

=  15.29 
=  12.05 

72 
73 

5 

30  = 

41.67 

42 
43 

=  58.33 

1912         .      . 

6 

30  = 

41.10 

=  58.90 

1911         .      . 

57 

16 

=  28.07 

41 

7 

19  = 

46.34 

22 

=  53.66 

1910         .      . 

48  . 

10 

=  20.83 

38 

8 

20  = 

52.63 

18 

=  47.37 

668 

70 

=  10.48 

598 

278  = 

46.49 

320 

=  53.51 

These  statistics  show  that  only  40  to  45  per  cent  of  the  premature 
infants  lived  to  the  school  age.  Twin  prematures  showed  a  some- 
what better  average— 50  per  cent. 

TWINS    WITH    A    BIRTH    WEIGHT   UP   TO   2500    GM.    IN   THEIR 
FIRST   EIGHT   YEARS. 


Year  of  birth. 


Followed 
through. 


In  1918 
at  end 
of  year 
of  life. 


Of  these 

still  alive, 
per  cent. 


Of  these 

dead, 
per  cent. 


1918 

9 

1917 

14 

1916 

26 

1915 

15 

1914 

18 

1913 

14 

1912 

11 

1911 

11 

1910 

10 

128 


5  =  27.7! 


18.18 
27.27 

20.00 


12  =     9.38 


9 
14 
26 


116 


5  =  55.56  4  =  44.44 
10  =  71.43  4  28.57 
15  =  57.69      11  =  42.31 


15 

3 

7  =  46.67 

8  =  53.33 

13 

4 

7  =  53.85 

6  =  46.15 

14 

5 

7  =  50.00 

7  =  50.00 

4  =  44.44 
7  =  87.50 
6  =  75.00 


5  =  55.56 

1  =  12.50 

2  =  25.00 


68  =  58.62      48  =  41.38 


In  concluding  it  may  be  said  that  the  future  of  the  prematures 
who  survive  is  on  the  whole  good.    They  seem  to  be  somewhat 


382 


THE  FUTURE  OF  THE  PREMATURE  INFANT 


more  subject  to  hydrocephalus  and  to  psychic  and  nervous  anoma- 
lies, such  as  enuresis  and  night  terrors,  and  to  anemia,  rachitis  and 
spasmophilia.  Many  are  precocious,  even  original  children.  They 
tend  to  remain  light  in  weight  and  short  in  length,  but  this  is  usually 
equalized  by  the  time  of  entering  school. 

It  is  generally  the  case  that  in  those  infants  who  survive,  most 
differences  between  the  premature  and  the  full-term  child  have 
disappeared  by  the  time  of  puberty,  and  therefore  every  effort 
should  be  made  to  preserve  all  perfectly  developed  premature 
infants. 

WALKING  AND  TALKING. 

/  It  is  well  known  that  in  premature  infants  we  may  not  expect 
the  development  of  certain  faculties,  namely,  speaking  and  walking, 
at  the  same  time  as  in  full-term  infants.  iJVYall  states  that  his 
premature  infants  learned  to  talk  seven  and  a  half  months  later 
and  learned  to  walk  six  months  later  than  full-term  children.  L  He 
also  reports  that  certain  speech  defects,  as'istuttering  and  stammer- 
ing, occurred  more  frequently  in  his  prematures.  These  differences, 
however,  became  equalized  later  on. 

In  general,  the  smaller  the  premature  at  birth,  the  greater  is 
the  delay  in  its  learning  to  talk.  It  is  rather  an  exception  to  the 
rule  when  infants  that  have  been  born  weighing  1000  to  1500  gm. 
learn  to  talk  before  they  are  two  years  old.  /  The  following  table 
shows  when  children  of  Ylppo's  series  learned  to  walk  and  to  talk 
a  few  words: 

The  age  and  number  of  children  when  they  were  able  to  speak: 

9  months  to  1  year 3 

1  year 9 

1  year,  3  months 48 


1 
1 

2 
2 
2 
3 

4 
Unknown 


18 

54 
1 

10 
1 
1 
1 

37 


The  age  and  number  of  children  when  they  started  to  walk: 

9  months  to  1  year 3 

1  year 15 

1  year,  3  months 46 


1 
1 
2 
2 
2 
2 
3 
3 
4 
Unknown 


52 
28 
25 


4 
1 

1 
26 


CONSTITUTIONAL  INFERIORITY 


383 


The  statements  as  to  the  time  at  which  the  child  spoke  the  firsl 
words,  and  when  it  started  to  walk  var\-  widely  in  individual 
cases.  Only  intelligent  mothers  are  able  to  make  reliable  state- 
ments pertaining  thereto.  On  the  other  hand  the  delay  in  learning 
to  talk  and  to  walk  depends  in  many  cases  not  upon  the  docility 
or  development  of  the  infants,  but  upon  the  efforts  of  its  mother 
or  nurse. 

From  the  preceding  facts  it  follows  that  the  small  prematures 
learn  the  first  sounds  and  the  first  words  on  an  average  of  one  year 
and  six  months.  This  occurs  then  about  six  months  later  than  in 
full-term  infants.  The  age  at  which  the  child  learns  to  walk  is 
about  the  same  as  that  at  which  it  learns  to  talk.  This  may  be 
regarded  as  a  proof  that  learning  to  walk  depends  in  a  healthy 
child  upon  its  mental  development. 

CONSTITUTIONAL    INFERIORITY. 

The  various  lesions,  either  of  traumatic  nature,  due  to  delivery 
itself  or  extra-uterine  life,  brought  on  by  deficient  resistance  or 
deficient  functional  capacity  of  the  different  organs,  result  in  various 
clinical  symptoms,  which  have  been  designated  under  the  collective 


Fig.  184. — Infant  born  at  thirty-six  weeks.  Birth  weight,  1500  gm.  Intense 
icterus,  melena,  double  inguinal,  lumbar  and  umbilical  hernia.  Photograph  taken 
at  six  months.     Still  showing  evidence  of  megacephalus. 

name  "  constitutional  inferiority."  Everything  seems  to  point  to  the 
fact  that  this  constitutional  inferiority  in  the  strict  sense  of  the 
word  does  not  occur  in  a  much  higher  degree  in  premature  infants 
than  in  full-term  children,  if  we  do  not  include  the  various  gross 
anatomical  malformations, 


384  THE  FUTURE  OF  THE  PREMATURE  INFANT 


Fia.  185. — Same  child,  aged  two  and  one-half  years. 


Fig.  186,— Same  child,  aged,  four  and  one-half  years.     Megacephalus  has  entirely 

disappeared. 


CONSTITUTIONAL  INFERIORITY 


:;.s:> 


We  have  reason  to  assume  that  main-  prematures  who  remain 
weaklings  in  their  later  life  and  show  other  signs  of  inferiority, 


Fig.  187. — Infant  born  at  thirty-four  weeks.     Complication,  spastic  paraplegia. 

suffered  from  some  constitutional  anomaly,  intra-uterine,  or  post- 
natal trauma,  or  were  born  in  a  state  of  physiological  immaturity. 


Fig.  188. — Child  shown  in  Fig.  187,  showing  standing  posture. 


This  view  seems  to  be  especially  strengthened  by  the  fact  that  the 
more  premature  and  the  smaller  the  infants  come  to  the  world, 


25 


386 


THE  FUTURE  OF  THE  PREMATURE  INFANT 


the  more  frequently  they  suffer  with  idiocy,  Little's  disease,  serious 
anemias,  rachitis  and  other  diseases  based  upon  the  condition  of 
deficient  resistance. 

The  proportional  diminution  of  various  pathological  symptoms 
with  increasing  birth  weight  would  be  difficult  to  understand  in 


Fig. 


189. — Child  shown  in  two  previous  illustrations,  showing  good  results  following 
tendon  transplantation.     Mental  development  in  advance  of  age. 


terms  of  congenital  constitutional  lesions.  Also  the  frequent 
disturbances  of  growth  in  premature  infants,  especially  during  the 
first  years  of  life,  have  some  connection  with  this  passing  poor 
condition  of  the  premature.  Later,  strikingly  good  reparation  of 
the  growth  disturbances  shows  best  that  this  state  is  not  dependent 
upon  congenital  constitutional  factors. 


MENTAL  DEVELOPMENT  OF  PREMATURE  INFANT      387 


THE  MENTAL  DEVELOPMENT    OF    THE  PREMATURE  INFANT 
DURING  EARLY  CHILDHOOD. 

In  order  to  review  this  subject  properly,  it  is  necessary  to  divide 
premature  infants  into  two  large  groups:  (1)  Prematures  without 
pathological  changes ;  and  (2)  those  born  with  pathological  changes 
due  to  constitutional  diseases  and  congenital  malformations.  In 
the  well-developed  fetus  which  has  not  been  damaged  during  the 
time  of  conception,  and  which  is  born  at  an  age  compatible  with  a 
physiological  development  necessary  to  meet  its  needs  for  life 
and  which  suffers  no  undue  traumata  during  or  following  birth,  a 
normal  mental  development  may  be  expected.  External  influ- 
ences will  affect  its  mental  growth  as  well  as  its  physical  develop- 
ment, therefore,  it  must  be  raised  in  a  suitable  environment  and 
be  judiciously  fed.  It  may  be  stated  that  the  longer  the  intra- 
uterine life  of  the  fetus,  the  less  the  dangers  of  interference  with 
its  normal  mental  growth.  It  is  quite  natural  to  expect,  therefore, 
that  these  immature  infants  are  more  subject  to  mental  disturb- 
ances and  defects  than  the  full-term  infant.  Abnormalities  in 
development  need  not  be  explained  by  anomalies  in  the  embryo,  but 
rather  may  be  due  to  direct  external  traumata  of  a  mechanical, 
dietetic  and  of  an  infectious  nature.  Thus,  there  remains  no 
other  choice  than  to  make  the  intra-uterine  and  extra-uterine 
noxa?  responsible  for  the  frequent  cerebral  disturbances,  be  they 
connected  with  spastic  states  or  idiocy,  with  or  without  spasms. 

It  is  our  experience  that  the  majority  of  premature  infants  bora 
after  the  thirty-second  week  into  a  proper  environment  without 
birth  injuries,  undergo  a  normal  mental  development.  That  these 
individuals  are  more  subject  to  rickets,  anemia  and  spasmophilia 
with  their  consequent  effects  on  the  nervous  system  is  not  to  be 
forgotten.  But  all  of  these  conditions  are  amenable  to  therapeutic 
procedures  with  only  a  limited  after  effect. 

In  the  second  group  belong  those  suffering  from  constitutional 
diseases  and  congenital  malformations.  These  individuals  cannot 
be  classified  in  groups  as  to  their  future  development,  but  each 
one  must  be  considered  individually.  While  congenital  lues  usually 
leaves  its  mark  in  the  full  term,  in  the  premature  it  is  even  more 
grave  in  its  consequences.  However,  much  can  be  expected  from 
proper  and  early  therapeutic  measures.  In  those  suffering  from 
hemorrhages  into  the  cerebrum  and  spinal  cord,  it  is  easy  to  under- 
stand that  in  the  premature  infant  that  has  survived  in  spite  of 
these  lesions  sequela?  may  manifest  themselves  in  later  life.  We 
would  especially  impress  upon  the  physician  the  fact  that  qoI  all 
infants  with  cerebral  hemorrhages  die  in  the  first  days  of  life  but 


388  THE  FUTURE  OF  THE  PREMATURE  INFANT 

that  many  survive.  Cerebral  hemorrhage  may  not  be  suspected 
until  late  mental  and  physical  signs  develop. 

The  prognosis  in  this  group  must  always  be  made  with  con- 
siderable reservations. 

However,  on  the  whole,  it  may  be  stated  that  mental  develop- 
ment goes  hand  in  hand  with  physical  development.  To  this 
broad  statement  there  are,  however,  many  exceptions,  and  while 
we  do  see  a  number  of  these  infants  with  good  physical  development 
who  are  of  low-grade  mentality,  in  our  personal  experience  we  have 
come  in  contact  with  a  larger  group  of  premature  infants  with  a 
high  grade  of  mental  development,  even  to  the  point  of  precocity. 
They  tend  to  remain  light  in  weight  and  short  in  length,  but  this 
is  usually  equalized  by  the  time  of  entering  school. 


INDEX  OF  AUTHORS. 


In  the  preparation  of  this  volume  the  following  authorities  were  consulted. 


Abramow,  S. 
Ahlfeld 

Ahlfeld  and  Hecker 

Alexander 

Auvard 

Babak 

Bade 

Ballantyne 

Billiard 

Berthod 

Birk 

Bouchut 

Brown,  Alan 

Budin 

Camerer 

Caspar 

Chalier,  J. 

Chiari 

Clementovsky 

Cohnheim 

Colerat 

Coo,  P. 

Cragin,  E.  B. 

Crede 

Cruse 

Czerny 

Czerny-Keller 

De  Lee 

Delmas 

Diffre 

Dubois  and  Dubois 

Epstein 

Escherich  and  Pfaundler 

Eustache 

Feer 

Fischer 

Franck 

Frank 

Freirichs 

Friedenthal 

Furmann 

( (anghofer  and  Langer 

( lartncr 

Gundobin 

Hartniann 

II  assel  wander 

Hearson 

Hecker 

Heller 

Hess,  A.  J. 

Hirsch 


His 

Hoeniger 

Holt 

Hougouneng 

Howland  and  Dana 

Buenekens 

Hutinel  and  Delestre 

Hymanson  and  Kahn 

Ibrahim 

Ibrahim  and  Gross 

Jaeggis 

Jaschke 

Jastrowitz 

Jeans 

Jeans  and  Cooke 

Kendall  and  Day 

Kleinschmidt 

Knopf elmacher 

Krieber-Mall 

Kunckel 

Lambert  z 

Lande 

Landois 

Langer 

Langstein 

Langstein-Meyer 

Lesage  and  Kuriansky 

Lichtenstein 

Limbeck 

Link 

Lion 

Litzenberg 

Lomer 

Luenberger 

Mall 

McCollum 

Meeh 

Meeh  and  Lissauer 

Mensi 

Merkel,  H. 

Miller 

Minkowski  and  Xyuvn 

Molischott 

Morse  and  Talbot 

Nathan  and  Langstein 

Nicoll 

Nothmann 

Nobecourt  and  Lemaire 

Oberwarth 

Oppenheimer 

Ostrcil 


( )swald 

Pacchioni 

Pajot 

Polanos 

Parrot 

Pasquad 

Passini 

Pehu,  M. 

Peiser 

Pfaundler 

Phemister 

Pies 

Planchu 

Planchu  and  Devin 

Poirier 

Potel  and  Hahn 

Quincke 

Ramsay  and  Alley 

Rauber-Kopsch 

Reiche 

Rodda 

Rollet,  H. 

Rommel 

Rusz 

Salge 

Samelson 

Schabort 

Schauta 

Schloss 

Schridde 

Sehroeder 

Schwegel 

Sedgwick 

Sherman 

Shick 

Ssytcheff 

Stratz 

Tarnier 

Taylor 

Theyson 

Trumpp 

Vierordt 

Virchow 

Von  Reuss 

Von  Winckel 

Wallich  and  Fruhinsholz 

Weaver  and  Tunnicliff 

Weldi- 

Weissenberg 

Ylppo 
Zweifel 


GENERAL  INDEX. 


Acetone  bodies,  73 
Age,  advantages  of  roentgenograph^ 
methods  of  determining,  101 
estimation,  limitation  of  accuracy, 

100 
exact,  difficulty  of  determining,  28 
of  parents  a  factor  in  premature 

labor,  25 
as  shown  by  development  of  head, 

79 
sternum  unreliable  as  index  of,  101 
as  told  by  skeletal  development,  77 
Albumin  as  factor  in  causing  induction 

of  labor,  370 
Albuminuria,  common  in  prematures, 

73 
Ammonia  in  atelectasis,  258 

in  cyanosis,  244 
Anemia,  351 

appetite  in,  353 

arsenic  in,  353 

in  early  childhood,  holdover  from 

prematurity,  378 
etiology  of,  352 
symptoms  of,  352 
treatment  of,  353 
Anomalous  position  of  fetus  cause  of 

premature  labor,  24 
Anorexia,  271 

gavage  in,  272 
Anus,  inspection  of,  in  new  born,  150 
Arsenic  in  anemia,  353 

therapy  in  syphilis,  335 
Asepsis  during  and  post  delivery  neces- 
sary in  preventing  sepsis,  318 
Aseptic  condition  necessarv  for  milk, 

184 
Asphyxia,  133 

diagnosis  of,  239 
etiology  of,  235 
morbid  anatomy  of,  237 
neonatorum,  235 
oxygen  in,  240 
prognosis  of,  239 
sequelae  of,  238 
symptoms  of,  237 
treatment  of,  239 
violent  measures  for  artificial  respi- 
ration contraindicated  in,  302 


Atelectasis,  ammonia  in,  258 
diagnosis  of,  253 

differential,  254 
oxygen  in,  258 
pathology  of,  251 
physical  signs  of,  253 
prognosis  of,  254 
symptoms  of,  252 
treatment  of,  255 

Atrophy  and  marasmus,  281 


B 


Bacillary  infections,  treatment  of,  285 
Bacteria  found  in  sepsis,  311 
influence  of  diet  on,  30 
Bacteriology  of  gastro-intestinal  tract, 

64 
Bath,  mustard,  in  atelectasis,  256 
in  pneumonia,  264 
value  of,  in  collapse  in  sepsis,  319 
Bed,  heated,  in  home,  168 
Bile-duet  affections,  causes  of,  289 
Blood,  bacteria  in,  in  sepsis,  311 
cell  content  of,  67 
changes  in  acidosis,  265 
coagulating  time  in  new  born,  dis- 
turbance in,  302 
coagulation  and  bleeding  time  of, 

67 
differential  cell  count,  68 
hemoglobin  content,  68 
longitudinal  sinus  best  source  for 
obtaining,  for  examination,  317 
subcutaneous  injection  of  normal, 
in  delayed  or  slow  bleeding,  302 
sugar  determination,  71 
transfusion  of,  in  anemia,  354 
Blood-pressure  in  mature  infant,  67 
Body  surface,  rules  for  estimation,  47 
temperature  of,  39 
weight  and  measurement,  29,  31, 
32 
Hoi  tic  nursing  for  prematures,  172 
Bowels,  condition  of,  28 
Brain,  weight  of,  37 
Breasl  milk,  average  amounl  required 
during      first      twentv-one 
days,  lsi) 
conditions  influencing,  109 


392 


GENERAL  INDEX 


Breast  milk,  conditions,  quality  of,  124 
asthenia  and  anemia, 

110 
drugs,  110 
fissures,  109 
mastitis,  110 
mental      conditions, 

110 
menstruation,  110 
simple  engorgement, 
109 
Breast-feeding  in  infants  with  rhinitis, 
247 
methods,  171 
Bronchial  affections,  250 


Calcium,  deficiency  of,  in  rickets,  351 
in  spasmophilia,  360 
in  tetany,  357 
Carbohydrate  ferments,  62 

lactose,  62 
Cardiovascular  system,  66 
Care  and  nursing,  conditions  of  success 
in,  131 
immediate,  of  infants,  132 
preparation  for  infant's  birth,  131 
requirements  for  hospital  nursery 

unit,  135 
treatment  of  cord,  133 
Castor  oil  in  bacillary  infections,  285 
in  constipation,  279 
in  inanition  fever.  272 
Catheter  feeding  in  nervous  and  mental 
disturbances,  302 
number  of  feedings,  178 
utensils  for,  175 
Causes  of  premature  birth,  371 
Cereal,  203 

Characteristics  deciding  maturity,  17 
Chronic  affections  as  cause  of  prema- 
turity, 22 
"Cigarette"  bandage  in  hernia,  297 
Circulatory  weakness,  cause  of  edema, 

343 
Clinical  features  of  prematures,  27,  28 
Clothing  outfit  of  infant,  153 
essentials  for,  157 
necessity  of  warm,  169 
Cod-liver  oil  in  rickets,  351 

in  spasmophilia,  360 
Colon  flushing  in  inanition  fever,  272 
Congenital  debility,  causes  of,  18 
Congenitally  debilitated  infants,  17 
Constipation,  causes  of,  279 

increase  water  intake  in,  279 
Convulsions,  spasmophilic,  310 
Cord,  treatment  of,  in  delayed  separa- 
tion, 150 
Cyanosis,  241 


Cyanosis,  administration  of  water  in, 
245 
causes  of,  242 

danger  of  manipulation  in,  245 
diagnosis  of,  243 
hot  bath  in,  244 
lavage  in,  245 
oxygen  in,  244 
prognosis  of,  243 
respiration  in,  243 
symptoms  and  treatment  of,  243 


Death,  apparent,  two  forms  of,  52 
cerebral  hemorrhage  as  cause  of,  in 

new  born,  302 
due  to  poor  intra-uterine  develop- 
ment, 34 
fetal  age  as  factor  in,  262 
meningitis  as  cause  of,  309 
refrigeration  as  cause  of,  169 
Deformity,  effect  of,  on  future  of  pre- 
matures, 372 
Developmental  features  by  months,  29 
Diabetes,  cause  of  premature  labor,  25 
Diarrhea  in  indigestion,  277 
Digestive  disturbances  accompanying 

parenteral  infections,  281 
Diet,  improper  regimen  in,  factor  in 
rickets,  350 
mixed,  203 
no  change  in,  unless  well  indicated, 

180 
in  rickets,  351 

too  liberal  in  mothers,  causeof  indi- 
gestion in  infants,  278 
Diseases  of  urinary  tract,  299 

pyelocystitis,  300 
Dressing  the  baby,  156 
Dropsy,  congenital,  344 
Ductus  Botalli,  closure  of,  38 
Dysenteric  affections,  medicinal  treat- 
ment of,  285 

E 

Edema,  342 

etiology  of,  342 

symptoms  of,  343 
Electric  hyperirritability  in  tetany,  355 
Encephalitis,  308 

interstitialis  congenita,  308 

septic,  309 
Erepsion,  62 

Erythroblastosis  fetalis,  344 
Etiology  of  prematurity,  19 
Exophthalmic  goiter,  cause  of  prema- 
ture labor,  24 
Exophthalmos,  occurrence  of,  in  mega- 

cephalous,  308 
Eyes,  74 


GENERAL  INDEX 


393 


Faulty  nutrition  of  fetus,  cause  of  pre- 
mature labor,  25 
Feeblemindedness  as  caused  by  prema- 
turity, 379 
Feeding  after  twenty-first  day,  184 
amount  necessary  in  twenty-four 

hours,  180 
an  individual  problem,  179 
artificial,  199 

amounts  to  be  fed,  202 
boiling  mixtures,  200 
buttermilk  and  skimmed-milk 

mixtures,  201 
as  increasing  susceptibility  to 

infection,  314 
quality  and  quantity  of,  200 
in  atelectasis,  an  important  prob- 
lem, 257 
cereal,  203 
methods,  171 

breast  milk,  171 
by  catheter,  174,  178,  180 
with  infants  too  weak  to 
nurse,  172 
mixed,  185 

vegetable  soup  in,  203 
Ferments,  carbohydrates,  62 
diastase,  62 
erepsin,  62 
hydrochloric  acid,  61 
invertin,  62 
lipase,  62 
maltase,  62 
pepsin,  61 
ptyalin,  62 
rennin,  61 
saccharose,  62 
secretin,  62 
steapsin,  63 
trypsin,  62 
Fluid  administration  in  underfeeding, 
281 
intake,  by  mouth,  to  be  pushed,  in 
sepsis,  319 
in  twenty-four  hours,  151 
Food,  infants,  168 

lack  of,  cause  of  insufficient  heat 

production,  41 
requirements  in  calories,  182 
Full-term  infant,  definition  of,  17 

newborn,  body  characteristics 
of,  35 


G 


Gallstones,  290 

Gastro-intestinal  tract  diseases,  266 
anorexia,  271 
bacteriology  of,  64 


Gastro-intestina]   tract    diseases,   can- 
crum  oris,  269 
constipation,  279 

dysenteric    affc  cl  io  n  b, 
medicinal  treatment  of. 

285 
enteral  infect  ions,  282 
inanition  fever,  272 
indigestion,  276 
insufficiency     dependent 
on  developmental  lack 
271 
portal  of  entry  for  bac- 
teria, in  sepsis,  313 
sprue,  266 

stomatitis,  etiology  of,  268 
of  oral  cavity,  266 
prognosis  of,  268 
treatment  of,  268 
various  types  of,  267 
Gavage  in  anorexia,  272 
Genito-urinary  system,  72 
Growth,  41 

fetal,inhibited  by  maternal  disease, 
46 

H 

Health  of  mother,  important  in  future 

of  premature,  370 
Heart  disease,  cause  of  premature  labor, 

24 
Heated  beds,  dangers  in  use  of,  221 

home-made,  223 
Hemorrhage  present  in  septic  jaundice, 

288 
Hepatic  parenchyma,  affection  of,  291 

vessels,  affections  of,  290 
Hernia,  cigarette  bandage  in,  297 
congenital  diaphragmatic,  293 
umbilical  and  inguinal,  294 
ventral  and  lumbar,  294 
Hess  bed,  advantages  of,  215 
care  of,  218 

comparative  measurements  of 
temperature  in,  219 
,  construction  of,  216 
Home-made  bed  (Brown  .  223 
(Litzenberg),  224 
specifications  of,  22.5 
temperature    maintained    by 
hot-water  bottles  in,  I'L'o 
Hospital  nursery,  requirements  of,  1M7 
staff  of,  146 
records,  159 
Hunger  contractions,  (il 
Hydrocephalus,  303 
Hydrochloric    acid,    presence    of,    in 

stomach,  61 
Hydrotherapy  in  pneumonia,  264 
ELygiene  of  mother,  107 

air  and  exercise,  108 
care  of  bowels,  10S 


394 


GENERAL  INDEX 


Hygiene  of  mother,  care  of  breasts,  108 

diet,  107 
Hypothermia,  cause  and  nature  of,  40 


Icterus  catarrhalis,  291 

frequent,  in  septic  infant,  315 

neonatorum,  286 

pallor  of  skin,  forerunner  of,   in 

anemia,  352 
stasis  of  bile,  as  cause  of,  287 
symptoms  and  diagnosis  of,  288 
treatment  of,  289 
Idiocy,  Mongolian,  prevalence  of,  309 
Illegitimacy,  factor  in  survival  of  pre- 
matures, 373 
Immature  infants,  definition  of,  19 
Inanition  fever,  272 
Incubator  room  in  Michael  Reese  Hos- 
pital, 228 
requirements  of,  217 
in  University  of  California,  228 
Incubators,  205 

general  requirements  in  care  of,  222 
history  of,  205 
relative  humidity  of,  217 
requisites  in,  215 
room  or  giant,  226 
transportation  of,  229 
De  Lee,  231 
Hess,  230 
Indigestion,  276 

dehydration  in,  278 
stools  in,  276 
treatment  of,  276 
medical,  277 
Infection,    intrapartum    and    postpar- 
tum, in  sepsis,  312 
spread  by  carelessness,  282 
Infectious  diseases,  cause  of  premature 
labor,  24 
effect  of,  on  survival  of  prema- 
tures, 373 
Intestinal    flora,    cause   of    dysenteric 
conditions,  284 
tract,  permeable  to  foreign  pro- 
teins, 63 
Iron,  important  in  anemia,  352 
stored  by  fetus,  69 
therapy  in  anemia,  353 


Jaundice,  family  acholuric,  289 
septic,  288 
syphilitic,  289 


Labor,  preparation  for,  169 
Lavage  in  cyanosis,  245 


Lavage  in  vomiting,  275 

Life  history  of  prematures,  factors  in, 

18 
Lipase,  62 

Liver,  acute  yellow  atrophy  of,  291 
congenital  tumors  of,  292 
decreased  size  of  capillaries  of,  as 
cause  of  icterus  neonatorum,  287 
diseases  of,  286 
fatty  degeneration  of,  291 
Lumbar  puncture  in  megacephalus,  306 
in   nervous   and   mental   disturb- 
ances, 302 
Lungs,  congestion  of,  258 

infection  of,  bacilli  in,  259 
pathology  of,  259 
Lymphatic  glands  in  syphilis,  323 
system,  72 


M 


Mammary  glands,  77 
Maramus,  danger  of,  281 
Measurements,  29,  31,  32 

of  assistance  in  estimating  viabil- 
ity, 369 
Meconium,  constituents  of,  64 
Megacephalus,  303 
definition  of,  307 

differential  diagnosis  from  occur- 
rence in  rickets,  330 
lumbar  puncture  in,  as  diagnostic 

measure,  306 
occurrence  of,  in  rickets,  346 
prevention  of,  in  prematures,  307 
symptoms     often     appearing     at 
birth,  304 
Meningitis,  309 

Mental    and    nervous     disturbances, 
catheter  feeding  in,  302 
spastic  paraplegia  in,  301 
treatment  of,  301 
development    of     prematures    in 
early  childhood,  387 
Mercury  therapy  in  syphilis,  333 
Metabolism  of  prematures,  65 
Milk,    buttermilk    and    skimmed-milk 
mixtures,  201 
chymogen,  201 

relative  caloric  values  in,  202 
stations,  143 
Mineral  content  abnormal  in  prema- 
tures, 348 
Mixed  diet,  203 
Mortality,  general,  374 
Multiple  pregnancy,  cause  of  prema- 
ture labor,  25 


N 


Nasal  passage,  diseases  of,  246 
treatment  of,  246 


GENERAL  INDEX 


395 


Nephritis,  cause  of  premature  labor,  22 
Nervous  disturbances,  epilepsy  in,  303 

megacephalus,  303 

system,  65 

in  syphilis,  330 
Nitroglycerine  in  cyanosis,  244 
Noma  (cancrum  oris),  269 
Nursing  axioms,  107 

bottle  for  prematures,  172 

daily  routine,  146 

hygiene  of  mother,  107 

maternal,  111 

in  tuberculosis,  341 

method  of  drawing  milk,  125 

regularity  in,  42 

requirements  for,  in  home,  165 

by  syphilitic  mother,  332 

wet,  hospital  rules  for  handling, 
129 


Orange  juice  feeding,  203 

in  rickets,  351 
Omphalitis  in  sepsis,  316 
Organs,  characteristics  of    respiratory 
tract,  50 
internal,    weight    of,    in    mature 

infants,  37 
stomach,  53 
Osseous  development,  variations  in.  99 
Ossification  of  skeleton,  head,  80 

pelvic   girdle   and   lower   ex- 
tremities, 83 
ribs,  sternum  and  upper  ex- 
tremities, 87 
shoulder  girdle,  80 
vertebrae,  82 
in  weeks,  (diagram),  77 
eighth,  80 

eleventh  to  twelfth,  84 
ninth,  81 
seventeenth  to  twentieth, 

88 
seventh,  79 
tenth,  83 
thirteenth    to    sixteenth, 

87 
thirty-seventh  to  fortieth, 

96 
thirty-third     to     thirty- 
sixth,  96 
twenty-fifth    to    twenty- 
eighth,  92 
twenty-first    to    twenty- 
fourth,  90 
twenty-ninth   to    thirty- 
second,  96 
Oxycephalus,  307 

Oxygen  consumption  per  gram  body 
weight,  41 


Oxygen  in  asphyxia,  240 
in  cyanosis,  2  1  I 
in  pneumonia,  264 


Paraplegia,  corrective  measures  for. 

302 
Parathyroid  dysfunction  in  tetany,  358 
Parenteral  infection  accompanying  di- 
gestive disturbances,  283 
Pathological  processes  in   prematures, 

103-104 
Pepsin  present  in  gastric  mucosa,  6] 
Peritoneal  disorders,  pathogenesis,  292 
Peritoneum,  diseases  of,  292 
Peritonitis,  293 

Phosphorus  concentration  in  serum,  349 
role  of,  in  osseous  system,  350 
in  spasmophilia,  360 
Pneumonia,  258 

changes  of  position  in,  necessary, 

265 
collapse  and  cyanosis  in,  treatment 

of,  264 
diagnosis,    prognosis,    treatment, 

262 
general  treatment  of,  263 
hygiene  of,  264 
hydrotherapy  in,  264 
lobular,  symptoms  in,  261 
occurrence  in  sepsis,  316 
physical  signs  of,  261 
postnatal,  258 
Porencephaly,  308 
Premature  birth,  causes  of,  371-372 
definition  of,  17 

infants,  classification  of,  19,  103 
constitutional    inferiority   of, 

383 
growth  of,  364 
outlook  for,  377 
prognosis  of,  in  early  child- 
hood, 379 
labor,  causes  of,  19 

acute  infectious  diseases 

in,  24 
age  of  parents,  25 
anomalous     position     of 

fetus,  24 
chronic  affections,  22 

nephritis,  22 
diabetes,  25 
exophthalmic  goiter,  2  I 
faulty  nutrition  of  fetus, 

25 
heart  disease,  24 
multiple  pregnancy,  25 
season  of  year,  26 
syphilis,  22 
tuberculosis,  23 


396 


GENERAL  INDEX 


Premature  labor,  causes  of,  uterine  con- 
ditions, 24 
frequency  of,  26 
indications  for  induction  of,  23 
Prematurity,  not  mark  of  congenital 

inferiority,  310 
Prognosis  of  premature,  361 

deformity  in  relation  to,  372 
factors  affecting  future,  370, 

372 
general  conditions,  374 

mortality,  374 
illegitimacy  factor  in,  373 
infectious  diseases  in,  373 
Pulse-rate,  66 
Pyelocystitis,  300 


R 

Rachitis,  346 

definition  of,  350 

diet  in,  351 

in  early  childhood,  holdover  from 

prematurity,  378 
etiology  of,  348 
hygiene  important  in,  350 
Rennet,  casein  precipitated  by,  in  treat- 
ment of  vomiting,  275 
Rennin,  presence  of,  in  stomach,  61 
Respiration,  artificial,  violent  measures 
contraindicated,  302 
in  prematures,  51 
Roentgen  ray  in  stridor,  249 
Roentgenograms,  technic  of,  102 
Roentgenographic  diagnosis  in  syphilis, 
325 


Saline  solutions  in  intestinal  difficul- 
ties, 285 
Scleredema,  342 

Scurvy,  differentiation  from  osteomye- 
litis, 378 
Secretin,  62 
Skeletal  development,  77 

as  basis  for  age,  77 
Skin  and  adnexa,  74 

care  of,  150 
Sepsis,  active  treatment  of,  319 
affections  of  skin  in,  315 
bacteria  causative  of,  311 
course  of,  317 

general  manifestations  of,  314 
infections  in  time  of,  312 
portals  of  entry  for  bacteria,  312, 

313 
prognosis  for,  318 
sterilization,    reducing    incidence, 

314 
susceptibility   to,   in   prematures, 
314 


Skull,  measurement  of,  32 
Spasmophilic  convulsions,  310 
diathesis  of,  354 
differential  diagnosis  of,  358 
treatment  of,  359 
Spleen,  enlargement  of,  in  tuberculosis, 

340 
Stomach,  capacity  of,  55,  58 

physiology  of,  58 
Stools,  foamy,  from  gas  bacillus,  284 

in  indigestion,  278 
Stridors,  congenital,  247 
laryngeal,  247 
roentgen  ray  in,  249 
thymus,  248 

thyroid  gland  enlargement  in,  249 
Subcutaneous  infusions  in  nervous  and 

mental  disorders,  302 
Suffocation  from  external  causes,  249 
Syphilis,  320 

abdominal  organs  in,  328 
affections  of  eyes  and  ears  in,  330 
of    mucous    membranes  and 
skin  in,  321 
arsenic  in,  335 
circulatory  and  digestive  system 

in,  329 
as  cause  of  congenital  hydrocepha- 
lus, 303 
factor  in  prematurity,  22 
inunctions  in,  334 
kidneys  in,  329 
laboratory  diagnosis  in,  331 
megacephalus     in,     differentiated 

from  that  in  rickets,  330 
mercury  therapy  in,  333 
nervous  system  in,  330 
osseous  system  in,  324 

roentgenographic  diagno- 
sis in,  325 
percentage  of,  in  parents,  320 
prophylaxis  of,  332 
purse-string  deformity  in,  323 
respiratory  system  in,  328 
treatment,  332 

Wassermann  reaction  not  always 
positive  in,  331 


Talking,  age  of,  in  prematures,  382 
Temperature,  how  taken,  151 
subnormal,  cause  of,  151 

as  factor  in  infection  in  prema- 
tures, 314 
Tetany,  354 

electric  hyperirritability  in,   355, 

356 
etiology  and  symptoms  of,  355 
parathyroid  deficiency  in,  358 
Trypsin,  62 


GENERAL  INDEX 


397 


Tubercle  bacilli,  entrance  of,  into  fetus, 

337 
Tuberculosis    as    cause   of    congenital 
debility,  336 
of  premature  labor,  23 
effect  of,  on  development  of  fetus, 
339 
on  mother,  338 
etiologic  factor  in  prematurity,  338 
results  of,  affecting  future  develop- 
ment, 340 
treatment,  340 


U 


Underfeeding,  280 

factor  in  development  of  rickets, 
349 
Urinary    diseases,  'eclampsia    neona- 
torum, 300 
nephritis  in  mother  causing  shrun- 
ken kidneys  in  infant,  299 
Urination,  delayed,  measures  in,  149 
Urine,  72,  73 

acetone  bodies  in,  74 
albumin  in,  73 
in  prematures,  28 
Uterine  conditions  cause  of  premature 
labor,  24 


Variations  in  osseous  development,  99 
Vegetable  soup,  203 


Vomiting,  273 

factor  in  dysenteric  affections,  284 
feeding  in,  275 
treatment  in,  27  1 


W 


Walking,  age  of,  in  prematures,  382 
Water  administration  by  catheter,  1M 
intake,  increased,  in  constipation, 

279 
in  sclerema,  344 
requirements  dependent  on,  184 
Weaklings,  definition  of,  17 
Weight  as  factor  in  survival,  363 

caloric  requirement  per  kilogram  of 

body,  182 
gain  in,  tabulated,  1  1 
of  kidneys,  39 
of  liver,  38 

loss  of,  during  first  days,  152 
initial  cause  of,  43 
prevention  of ,  by  feeding,  13 
rapid  in  sepsis,  315 
of  organs  in  mature  new  born,  37 
of  prematures,  27 
in  relation  to  body  surface,    17 
unreliability     of,    in     estimating 
fetal  age,  363 
Wet  nurse,  114 

diet  of,  121 
examination  of,  116 
hygiene  of,  119 
uniform,  120 


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